§164.308(a)(1)(ii)(B): Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with § 164.306(a).
Does the entity have policies and procedures in place regarding a risk management process sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level?
Has the entity implemented security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level?
Obtain and review policies and procedure related to risk management. Evaluate and determine if the documents identify how risk will be managed, what is considered an acceptable level of risk based on management approval, the frequency of reviewing ongoing risks, and identify workforce members’ roles in the risk management process.
Obtain and review documentation demonstrating the security measures implemented and/or in the process of being implemented as a result of the risk analysis or assessment. Evaluate and determine whether the implemented security measures appropriately respond to the threats and vulnerabilities identified in the risk analysis according to the risk rating and that such security measures are sufficient to mitigate or remediate identified risks to an acceptable level.