Workforce Security
164.308(a)(2)
Administrative Safeguards
High Risk
Moderate
Implement policies and procedures to ensure that all members of the workforce have appropriate access to electronic protected health information (ePHI) and to prevent those workforce members who do not have access from obtaining access to ePHI.
Implementation Guidance
Develop and implement workforce security policies including:
• Background checks and screening procedures for new hires
• Access authorization procedures based on job functions
• Regular review and update of access permissions
• Procedures for terminating access when employees leave
• Monitoring of workforce access to ePHI
• Training on workforce security policies
Key components:
- Pre-employment screening and background checks
- Role-based access control (RBAC)
- Regular access reviews and recertification
- Proper termination procedures
- Ongoing monitoring and auditing
• Background checks and screening procedures for new hires
• Access authorization procedures based on job functions
• Regular review and update of access permissions
• Procedures for terminating access when employees leave
• Monitoring of workforce access to ePHI
• Training on workforce security policies
Key components:
- Pre-employment screening and background checks
- Role-based access control (RBAC)
- Regular access reviews and recertification
- Proper termination procedures
- Ongoing monitoring and auditing
NIST References
NIST SP 800-66 Rev. 2: Section 3.1.2
NIST Cybersecurity Framework: PR.AC-1, PR.AC-2, PR.AC-3, PR.AC-4, PR.AC-5, PR.AC-6, PR.AC-7
NIST SP 800-53: PS-1, PS-2, PS-3, PS-4, PS-5, PS-6, PS-7, PS-8
NIST Cybersecurity Framework: PR.AC-1, PR.AC-2, PR.AC-3, PR.AC-4, PR.AC-5, PR.AC-6, PR.AC-7
NIST SP 800-53: PS-1, PS-2, PS-3, PS-4, PS-5, PS-6, PS-7, PS-8
Best Practices
• Implement comprehensive background check procedures
• Use role-based access control (RBAC) principles
• Conduct regular access reviews and recertification
• Implement proper termination procedures
• Monitor and audit workforce access regularly
• Provide ongoing security training
• Document all access decisions and changes
• Use role-based access control (RBAC) principles
• Conduct regular access reviews and recertification
• Implement proper termination procedures
• Monitor and audit workforce access regularly
• Provide ongoing security training
• Document all access decisions and changes
Testing Procedures
• Review workforce security policies and procedures
• Verify background check procedures are implemented
• Test access authorization processes
• Review access review and recertification procedures
• Verify termination procedures are followed
• Test monitoring and auditing capabilities
• Review training records and materials
• Verify background check procedures are implemented
• Test access authorization processes
• Review access review and recertification procedures
• Verify termination procedures are followed
• Test monitoring and auditing capabilities
• Review training records and materials
Frequently Asked Questions
Q: What level of background check is required?
A: The level of background check should be appropriate to the level of access to ePHI. Higher levels of access may require more comprehensive checks.
Q: How often should access be reviewed?
A: Access should be reviewed at least annually, or more frequently for high-risk positions or when job functions change.
Q: What should be included in termination procedures?
A: Termination procedures should include immediate revocation of all system access, return of equipment, and documentation of the termination process.
A: The level of background check should be appropriate to the level of access to ePHI. Higher levels of access may require more comprehensive checks.
Q: How often should access be reviewed?
A: Access should be reviewed at least annually, or more frequently for high-risk positions or when job functions change.
Q: What should be included in termination procedures?
A: Termination procedures should include immediate revocation of all system access, return of equipment, and documentation of the termination process.
Control Information
Control ID:
164.308(a)(2)
164.308(a)(2)
Category:
Administrative Safeguards
Administrative Safeguards
Subcategory:
Security Management Process
Security Management Process
Risk Level:
High
High
Implementation Difficulty:
Moderate
Moderate
Estimated Cost:
Medium
Medium
Implementation Timeframe:
2-4 months
2-4 months
Views:
12
12
Last Updated:
Oct 1, 2025
Oct 1, 2025
Related Controls
Additional Resources
• NIST SP 800-66 Rev. 2: Workforce Security Guidance
• HHS Workforce Security Guidance
• Background Check Best Practices
• Role-Based Access Control Implementation Guide
• Termination Procedures Checklist
• HHS Workforce Security Guidance
• Background Check Best Practices
• Role-Based Access Control Implementation Guide
• Termination Procedures Checklist