164.314(b)(2) Implementation Specifications for Group Health Plans
The plan documents of the group health plan must be amended to incorporate provisions to require the plan sponsor to implement administrative, physical, and technical safeguards that reasonably and appropriately protect
8
artefacts
0
held by a system
2
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
system holds itEvidence a system already holds
none for this control
periodic reviewEvidence produced at each review
- Records of reported incidents · Policy repository / GRC workspace
- Legal counsel review records · Policy repository / GRC workspace
governing documentDocuments that govern the control
- Plan document amendments containing all four required provisions · Policy repository / GRC workspace
- Plan sponsor safeguards documentation (administrative, physical, technical) · Policy repository / GRC workspace
- Adequate separation procedures and evidence · Policy repository / GRC workspace
- Plan sponsor agent agreements with security obligations · Vendor register / contract repository
- Incident reporting procedures from plan sponsor to plan · Policy repository / GRC workspace
- Annual validation of plan sponsor compliance · Policy repository / GRC workspace
First move
This control is evidenced by people and documents, not systems. Put the document under version control with an owner and review date, and log each review as a record with reviewer and date. Do not try to automate it.
Common gaps auditors find
- Plan amendments missing one or more required provisions
- Plan sponsor administrative safeguards weak
- Adequate separation not implemented in HR or IT
- Agent agreements lack security obligations
- Incidents not reported to plan
- No annual validation
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 sheet164.314(b)(1) Requirements for Group Health Plans (Standard) · 164.316(a) Policies and Procedures (Standard)