What evidence do auditors commonly ask for on 164.310(a)(2)(i) Contingency Operations (Addressable)?

Emergency facility access list; Procedures for revoking after incident; Audit log of emergency entries; 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.

HIPAA Security Rule · Physical

`164.310(a)(2)(i)` Contingency Operations (Addressable)

Establish procedures allowing facility access in support of restoration of lost data under disaster recovery plan and emergency mode operations plan.

Source: HIPAA Security Rule, 164.310(a)(2)(i). 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

moderate

to go live

SIEM / log platform

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

Audit log of emergency entries · SIEM / log platform

periodic reviewEvidence produced at each review

none for this control

governing documentDocuments that govern the control

Emergency facility access list · Policy repository / GRC workspace
Procedures for revoking after incident · 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

Start with the 1 of 4 artefacts that already live in a system (SIEM / log platform); keep the periodic reviews but log each one as a dated record with a named reviewer.

Common gaps auditors find

Emergency access not reviewed
No audit log of who entered during incident

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

164.310(a)(1) Facility Access Controls (Standard) · 164.310(a)(2)(ii) Facility Security Plan (Addressable)