HIPAA Remediation SOP¶

Sub-procedure of hipaa-gap-sop.md

Overview¶

Detailed procedures for remediating identified HIPAA compliance gaps, including prioritization methodology, remediation planning, implementation guidance, and validation requirements. This sub-procedure covers the post-assessment remediation pathway.

Scope¶

Parent SOP: HIPAA Gap Assessment Pillar: Protect (Security & Compliance) Service Area: HIPAA Compliance Remediation

Prerequisites¶

Parent SOP requirements met
Gap Assessment Report delivered and accepted
Remediation engagement scoped and approved
Client remediation team identified
Project management tools and access established
Weekly status meeting cadence confirmed

Procedure¶

Step 1: Remediation Prioritization¶

Objective: Establish risk-based remediation sequence

Priority Framework:

Priority	Criteria	Timeline	Resource Intensity
Critical	Immediate PHI risk, active vulnerability, OCR audit trigger	0-30 days	High
High	Significant control gap, probable finding	30-60 days	Medium-High
Medium	Moderate gap, possible finding, improvement area	60-90 days	Medium
Low	Minor gap, best practice, optimization	90-180 days	Low

Prioritization Factors: - Likelihood of exploitation or audit finding - Impact to PHI confidentiality, integrity, or availability - Effort required for remediation - Dependencies on other remediation activities - Resource availability

Step 2: Remediation Plan Development¶

Objective: Create actionable remediation roadmap

Plan Components:

Finding-Level Detail
Finding ID and reference to gap assessment
HIPAA requirement citation
Current state description
Target state description
Remediation steps
Owner assignment
Target completion date
Validation criteria
Phase Structure

Phase	Timeline	Focus Areas
Immediate	Days 1-30	Critical findings, quick wins
Short-Term	Days 30-60	High-priority controls, policy gaps
Medium-Term	Days 60-90	Technical implementations, training
Long-Term	Days 90-180	Program maturity, optimization

Resource Planning
Internal resource requirements by role
External resource requirements (SBK, vendors)
Budget allocation by phase
Procurement timelines for tools/services

Step 3: Policy and Procedure Remediation¶

Objective: Address administrative safeguard documentation gaps

Standard Deliverables:

Policy/Procedure	Template Provided	Customization Required
Information Security Policy	Yes	Organization-specific context
Access Control Policy	Yes	System-specific procedures
Risk Management Policy	Yes	Risk tolerance alignment
Incident Response Plan	Yes	Contact information, escalation
Workforce Security Procedures	Yes	HR process integration
Business Associate Management	Yes	Vendor inventory integration

Development Process: 1. Review SBK template against client environment 2. Customize for organizational structure and systems 3. Internal stakeholder review 4. Legal review (if applicable) 5. Executive approval 6. Staff communication and training 7. Document distribution and acknowledgment

Step 4: Technical Remediation¶

Objective: Implement technical safeguard controls

Common Technical Remediation Areas:

Control Area	Typical Remediation	Validation Method
Access Control	Implement MFA, configure RBAC	Access testing, configuration review
Encryption	Deploy encryption at rest/transit	Configuration verification, testing
Audit Logging	Configure SIEM, establish retention	Log review, retention verification
Endpoint Security	Deploy EDR, configure patching	Agent verification, patch status
Network Security	Implement segmentation, update rules	Firewall review, network testing

Technical Remediation Checklist:

MFA implemented for all PHI system access
Encryption enabled for all ePHI at rest
TLS 1.2+ configured for all ePHI in transit
Audit logs capturing all required events
Log retention configured for 6+ years
Automatic session timeout implemented
Unique user IDs assigned for all users
Backup and recovery procedures documented and tested

Step 5: Validation and Documentation¶

Objective: Verify remediation effectiveness and maintain evidence

Validation Process: 1. Confirm remediation activity completed per plan 2. Test control effectiveness 3. Collect evidence of implementation 4. Update gap assessment findings status 5. Document any residual risk with compensating controls

Evidence Requirements:

Control Type	Evidence Examples
Policy	Signed policy, version history, distribution records
Technical	Configuration screenshots, test results, scan reports
Administrative	Training records, access reviews, risk assessments
Physical	Badge logs, facility photos, visitor procedures

Deliverables¶

Deliverable	Format	Owner
Remediation Project Plan	Project management tool/Excel	Project Manager
Policy Templates (customized)	Word/PDF	SBK Consultant
Technical Implementation Guides	Word/PDF	Technical Lead
Weekly Status Reports	Email/Document	Project Manager
Remediation Evidence Package	Organized file structure	Client IT
Updated Gap Assessment Matrix	Excel	SBK Lead

Quality Gates¶

All Critical findings remediated within 30 days
All High findings remediated within 60 days
Policies reviewed and approved by appropriate authority
Technical controls validated through testing
Evidence collected for all remediated findings
Residual risks documented with compensating controls
Client sign-off on remediation completion

Last Updated: February 2026 Parent SOP: hipaa-gap-sop.md