EvidenceSheet
HIPAA Security Rule · Administrative

164.308(a)(7)(ii)(C) Emergency Mode Operation Plan (Required)

Establish procedures to enable continuation of critical processes and security of ePHI during emergency mode. NIST recommends documented manual workflows preserving access controls.

Source: HIPAA Security Rule, 164.308(a)(7)(ii)(C). 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.

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

4
artefacts
0
held by a system
0
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

none for this control

governing documentDocuments that govern the control

  • Emergency mode procedures · Policy repository / GRC workspace
  • Manual workflow documentation · Document repository
  • Emergency access controls · Document repository
  • Audit logging during degraded mode · 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

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)(7)(ii)(B) Disaster Recovery Plan (Required) · 164.308(a)(7)(ii)(D) Testing and Revision Procedures (Addressable)