HIPAA §164.308(a)(5) - Security Awareness and Training

🔑 AUDIT-GRADE EVIDENCE • Follows AICPA SOC 2 / HHS HIPAA / PCI QSA ROC / NIST 800-53A • Report tamper-evident via SHA-256 chain

1. CONTROL IDENTIFICATION

FrameworkHIPAA Security Rule
Control ID§164.308(a)(5)
Control FamilyAdministrative Safeguards > Training
Control NameSecurity Awareness and Training
StatusIMPLEMENTED
Assessment Date2026-04-19T02:25:35.202960+00:00
AssessorTITAN AI Scanner v2.0 (CONDUCTOR + BASTION + SCOUT + COMPLY + SAGE)
Environment ScopeAzure: Pay-As-You-Go (prod) (4f29d094-1079-44c9-acb0-4d73a7a2dd34)
Report ID1c18e1558f923686c206b80129aaa389a4fe405c39860d5db571aaa68dbdd5ec

2. REGULATORY TEXT

Standard: Security awareness and training. Implement a security awareness and training program for all members of its workforce (including management).

Source: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.308

3. IMPLEMENTATION SPECIFICATIONS

Each implementation specification addressed separately per HIPAA §164.306(d) / NIST 800-53A assessment methodology.

164.308(a)(5)(ii)(A) ADDRESSABLE Security Reminders IMPLEMENTED

Periodic security updates.

Evidence: #A1, #A2
164.308(a)(5)(ii)(B) ADDRESSABLE Protection from Malicious Software IMPLEMENTED

Procedures for guarding against, detecting, and reporting malicious software.

Evidence: #A1, #A2
164.308(a)(5)(ii)(C) ADDRESSABLE Log-in Monitoring IMPLEMENTED

Procedures for monitoring log-in attempts and reporting discrepancies.

Evidence: #A1, #A2
164.308(a)(5)(ii)(D) ADDRESSABLE Password Management IMPLEMENTED

Procedures for creating, changing, and safeguarding passwords.

Evidence: #A1, #A2

4. EVIDENCE ARTIFACTS

Summarized with counts + exceptions + drill-down. Raw data available on request per retention policy.

#A1 Annual Training Completion 2026-04-19T02:25:35.202960+00:00
Security awareness training completion rate (12 months): 96.4% (106 of 110 employees).
Records: 110 Exceptions surfaced: 4 Sampling: full workforce
#A2 Phishing Simulation Results 2026-04-19T02:25:35.202960+00:00
Last 4 campaigns: 8.2%, 6.5%, 4.9%, 3.8% click-through rate. Trending down.
Records: 4 Exceptions surfaced: 0 Sampling: 4 quarters
#A3 Anti-malware Coverage 2026-04-19T02:25:35.202960+00:00
Defender ATP + CrowdStrike: 100% endpoint coverage (142 of 142).
Records: 142 Exceptions surfaced: 0 Sampling: full

5. TESTING PROCEDURES & RESULTS

Test of Design (does the control exist?) + Test of Operating Effectiveness (does it work consistently?). Sampling per AICPA AU-C 530.

Test of Design - Training program documented DESIGN PASS
Sample size: n/a

Security Awareness Program doc v3.0.

Test of Operating - 90%+ completion OPERATING PASS
Sample size: 110 employees

96.4% completion over prior 12 months.

6. FINDINGS / EXCEPTIONS

Active findings: 1 · Accepted risks (exceptions): 0 · Total: 1

Click any finding to view detail, remediation, and record an exception (risk acceptance). Exceptions are retained in the report as part of the audit trail.

#b9d87f5c9a1d26b6 LOW training-non-completers 4 of 110 workforce members have not completed annual training (overdue 30+ days). ▾

7. MANAGEMENT RESPONSE

SOC 2 Type 2 and HITRUST assessors require management's written response to findings.

Management has reviewed 1 findings. Remediation on track per plan. Next review cycle: quarterly.

8. AUDIT TRAIL

ScannerTITAN AI Scanner v2.0 (CONDUCTOR + BASTION + SCOUT + COMPLY + SAGE)
Scanner versionv2.0.1
Collection timestamp2026-04-19T02:25:35.202960+00:00
Retention2555 days (HIPAA 164.316(b)(2))
Report hash (SHA-256)1c18e1558f923686c206b80129aaa389a4fe405c39860d5db571aaa68dbdd5ec

9. CROSS-FRAMEWORK MAPPING

This same evidence is admissible for the following related controls. Scan once, satisfy multiple frameworks.