What evidence do auditors commonly ask for on 164.308(a)(5)(ii)(D) Password Management (Addressable)?

Password policy aligned with NIST SP 800-63B; MFA deployment report; Password manager rollout records; Breached password screening configuration; 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)(5)(ii)(D)?

Forced rotation without compromise indicator

HIPAA Security Rule · Administrative

`164.308(a)(5)(ii)(D)` Password Management (Addressable)

Implement procedures for creating, changing, and safeguarding passwords. NIST recommends aligning to SP 800-63B authenticator assurance levels and considering multi-factor authentication for ePHI access.

Source: HIPAA Security Rule, 164.308(a)(5)(ii)(D). 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

easy

to go live

Identity provider / directory

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

Password policy aligned with NIST SP 800-63B · Identity provider / directory
MFA deployment report · Identity provider / directory
Breached password screening configuration · Identity provider / directory

periodic reviewEvidence produced at each review

Password manager rollout records · Identity provider / directory

governing documentDocuments that govern the control

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

Automate the pull from your Identity provider / directory. Scheduled export of users, roles and MFA state from the directory; access-review completion pulled from the IdP, not a spreadsheet.

Common gaps auditors find

Forced rotation without compromise indicator
No MFA for remote access to ePHI
Shared accounts with static passwords

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.

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164.308(a)(5)(ii)(C) Log-in Monitoring (Addressable) · 164.308(a)(6)(i) Security Incident Procedures (Standard)