HIPAA Technical Controls Audit for Santa Ana Healthcare Organizations

Assigns every workforce member a distinct login so activity in your EHR and supporting systems can be traced to a single person.

• •No shared or generic logins on EHR, billing, or workstation accounts
• •Accounts disabled the same day a provider or staff member leaves
• •Service and vendor accounts named and owned, not anonymous

Limits each user to the ePHI their job requires, supporting the minimum necessary standard rather than giving every staff member full record access.

• •Front desk, clinical, and billing roles scoped to different data sets
• •Documented review of who can view, edit, and export records
• •Access changes tied to a request and approval trail

Ends sessions after a period of inactivity so unattended workstations in exam rooms and reception areas do not leave ePHI exposed.

• •Screen lock and session timeout enforced by policy, not left to the user
• •Timeout intervals reasonable for clinical workflow yet short enough to protect open charts
• •Applied to EHR sessions, not just the operating system

Renders stored ePHI unreadable to anyone without the key, which also qualifies as a breach safe harbor when a device is lost or stolen.

• •Full-disk encryption on every laptop, desktop, and server holding ePHI
• •Encryption verified and reported, not assumed
• •Mobile devices and removable media covered by the same standard

Captures who accessed which record, when, and what they did, so unauthorized snooping or inappropriate access can be detected and proven.

• •Record-level access logging enabled in the EHR and retained per policy
• •Logs protected from edit or deletion by the users they track
• •Retention period documented and aligned with HIPAA and California requirements

Aggregates logs from endpoints, servers, firewalls, and cloud services so review is consistent rather than scattered across each system.

• •Logs forwarded to a central platform or SIEM, not left only on the source device
• •A defined cadence and owner for reviewing access and security events
• •Alerting on anomalies such as off-hours access or bulk record exports

Watches for indicators of compromise across the environment so an incident is caught early rather than discovered weeks later.

• •Endpoint detection and response deployed on systems that touch ePHI
• •Failed login and privilege escalation events surfaced for review
• •Documented process for escalating an alert into an incident response

Ensures records can be restored intact after ransomware, hardware failure, or accidental deletion, supporting both integrity and contingency requirements.

• •Backups run on a defined schedule covering all ePHI repositories
• •Recovery tested with documented results, not assumed to work
• •At least one copy stored offsite or in a separate cloud region from Santa Ana

Controls how systems holding ePHI are modified so unauthorized or untested changes do not corrupt data or open exposures.

• •Patch and update process documented for EHR servers and workstations
• •Configuration baselines recorded for critical systems
• •Changes to access and security settings tracked and reversible

Reduces the risk that ePHI is encrypted, altered, or destroyed by malicious software targeting healthcare organizations.

• •Managed endpoint protection on every device with ePHI access
• •Email filtering tuned for phishing aimed at clinical and billing staff
• •Application controls limiting what can execute on clinical workstations

Adds a second verification factor so a stolen or guessed password alone cannot reach ePHI in the EHR, email, or remote access.

• •Enforced on EHR, email, VPN, and any remote access to clinical systems
• •Applied to administrator and vendor accounts, not only standard staff
• •Phishing-resistant methods favored over SMS where the workflow allows

Sets enforceable standards for credential strength and lifecycle so weak or reused passwords do not undermine other controls.

• •Policy enforced by the system rather than left to staff discretion
• •Shared credentials eliminated in favor of individual accounts
• •Credentials for service accounts rotated and stored in a managed vault

Restricts and monitors the high-permission accounts that can change configurations or reach all ePHI, limiting damage from compromise or misuse.

• •Administrator accounts separated from day-to-day user accounts
• •Elevated access granted for specific tasks and reviewed regularly
• •Activity on privileged accounts logged and examined

Protects records as they move between systems, providers, and patients so intercepted traffic cannot be read.

• •Secure email or a patient portal used for any ePHI sent to patients
• •EHR, telehealth, and billing connections using current TLS standards
• •No ePHI sent over unencrypted email, fax-to-email, or messaging tools

Provides protected pathways for remote providers and after-hours staff so home and mobile connections do not bypass your safeguards.

• •Remote access through an encrypted VPN or vetted secure gateway
• •Personal devices governed by policy before they reach ePHI
• •Remote sessions logged and tied to a unique, authenticated user

Separates clinical systems, guest Wi-Fi, and medical devices so a compromise in one area does not expose ePHI elsewhere.

• •Patient and guest Wi-Fi isolated from systems holding ePHI
• •Firewall rules reviewed and documented, not left at defaults
• •Medical and IoT devices placed on a segment with limited reach

Identifies where ePHI lives, the threats to it, and the gaps in your safeguards, forming the foundation the rest of your controls are built on.

• •A current, written risk analysis covering all systems that touch ePHI
• •Findings tracked to remediation through a risk management plan
• •Analysis refreshed after major changes such as a new EHR or office

Documents how your safeguards operate and trains staff to follow them, which is required evidence during any HIPAA review.

• •Written security policies that match what your systems actually enforce
• •Documented workforce training with completion records retained
• •Sanction policy and incident reporting path known to staff

Confirms that every vendor handling ePHI on your behalf is under a signed agreement, closing a common compliance and breach-liability gap.

• •An inventory of vendors that create, receive, or store ePHI
• •A signed business associate agreement on file for each
• •Vendor list reviewed when new tools or services are added