What evidence do auditors commonly ask for on 164.308(a)(3)(ii)(B) Workforce Clearance Procedure (Addressable)?

Background check policy; Clearance determination records; Role-to-screening mapping; Re-screening schedule for sensitive roles; Documented addressable-specification decision: whether it is reasonable and appropriate in your environment, and if not, why, with the equivalent alternative adopted where one is.

What is the most common gap auditors find on 164.308(a)(3)(ii)(B)?

Screening not aligned to role sensitivity

HIPAA Security Rule · Administrative

`164.308(a)(3)(ii)(B)` Workforce Clearance Procedure (Addressable)

Determine that access to ePHI is appropriate. NIST recommends background screening proportionate to role sensitivity and documented clearance decisions.

Source: HIPAA Security Rule, 164.308(a)(3)(ii)(B). The statement above is our statement of the clause, read from the published text and cited so you can check it against the official text, not the instrument verbatim. Open HIPAA Security Rule in the compliance library.

Scope: Addressable, not optional: assess whether it is reasonable and appropriate; implement it, or document why not and adopt an equivalent alternative where reasonable (45 CFR 164.306(d)(3)).

Applies to covered entities and business associates. An addressable specification can be met by a documented, reasonable alternative.

artefacts

held by a system

at each review

hard

to go live

Policy repository / GRC workspace

where the evidence lives

teal = a system already holds it · olive = produced at each review. To go live: easy when half or more of the artefacts are already held by a system, moderate from a quarter to a half, hard below a quarter.

These are the artefacts auditors commonly ask for on this requirement, our guidance rather than text from the standard. Your assessor decides what is sufficient in your context, and asks for samples across the period when a report covers one.

system holds itEvidence a system already holds

none for this control

periodic reviewEvidence produced at each review

Clearance determination records · HR system / LMS

governing documentDocuments that govern the control

Background check policy · HR system / LMS
Role-to-screening mapping · Policy repository / GRC workspace
Re-screening schedule for sensitive roles · Policy repository / GRC workspace
Documented addressable-specification decision: whether it is reasonable and appropriate in your environment, and if not, why, with the equivalent alternative adopted where one is · Policy repository / GRC workspace

First move

No system holds this evidence for you: it is people and documents. Reminders and routing to the owner still save time. Put the document under version control with an owner and review date, and log each review as a record with reviewer and date.

Common gaps auditors find

Screening not aligned to role sensitivity
Contractors exempted
Re-screening not performed

Do this for your whole sheet

Paste the rows you run your controls from and get this mapping for every control at once, with the periodic-review ones flagged and a first move per row. No account for the first run.

Build my evidence sheet

164.308(a)(3)(ii)(A) Authorization and Supervision (Addressable) · 164.308(a)(3)(ii)(C) Termination Procedures (Addressable)