What evidence do auditors commonly ask for on 164.310(a)(2)(iii) Access Control and Validation Procedures (Addressable)?

Visitor procedures; Role-to-zone mapping; Badge access reports; Periodic access review of physical zones; 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 164.310(a)(2)(iii)?

All staff have facility-wide access

HIPAA Security Rule · Physical

`164.310(a)(2)(iii)` Access Control and Validation Procedures (Addressable)

Implement procedures to control and validate access to facilities based on role or function, including visitor control and access to software programs for testing and revision.

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

Badge access reports · Physical access / facilities

periodic reviewEvidence produced at each review

Periodic access review of physical zones · Physical access / facilities

governing documentDocuments that govern the control

Visitor procedures · Policy repository / GRC workspace
Role-to-zone mapping · 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

Mostly documents and reviews. Pull the 1 system-held artefact from your Physical access / facilities on a schedule; put the documents under version control with an owner and review date, and log each review as a dated record with a named reviewer.

Common gaps auditors find

All staff have facility-wide access
Visitor escorts not enforced
Physical access reviews 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

164.310(a)(2)(ii) Facility Security Plan (Addressable) · 164.310(a)(2)(iv) Maintenance Records (Addressable)