How To Have A Winning Facility Security Plan

By HIPAA-Guard | Updated: Sept. 28, 2024, 4:05 p.m.

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Facility Security Plan - Addressable - 45 CFR 164.310 (a)(2)(ii) A covered entity should address and implement adequate policies and procedures to safeguard the facility and the equipment within from unauthorized access, tampering, or theft. There should be controls in place such as locking doors, surveillance cameras, alarms, and other controls to protect property, personnel as well as data/information specifically PHI and ePHI.

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How to have a winning
Facility Security Plan
Physical Safeguards Mandated by HIPAA
Questionnaire
To consider when setting up Facility Security Plan
Does your organization put up signs warning that a certain area is restricted?
What are the procedures in place if someone is caught in an area that is designated as restricted?
Are workforce members trained to question these people, confront them, call a supervisor, call the police and so forth?
Are visitors given a physical token e.g. visitor badge to identify them as non employees?
Does your facility have proper lighting around to illuminate the dark areas at entry points or where workforce members tend to travel?
Are CCTV cameras installed to cover all entrances and exits to the facility? These are installed to capture activities that occur in critical areas such as the server room or records room.
Are these equipments checked on a daily basis to make sure that the system is working properly, date and time stamps are accurate, and to follow up on any events that may have occurred throughout the previous day?
Do the windows have alarms placed on them and/or equipped with glass break sensors or motion detection specially on critical areas and common passageways?
Facilities with roof access, are these secured with alarm contacts and locks to prevent entry from the outside?
Are these alarm systems under maintenance contracts and tested periodically (at least monthly) for proper operations?
Are the control panel for the alarm system out of public view i.e. placed either in a secure back area or by an entry door that is only used by workforce members?
Are equipment properly inventoried and tagged with ASSET CONTROL NUMBERS or ENGRAVING?
Are regular inventories conducted to make sure nothing has been lost or stolen?
Facility's janitorial services provided by cleaning companies, do they go through the same background checks as other workforce members?
Are the workforce members given photo identification badges that are required to be worn at all times during work hours in and outside the premises.

Are there procedures in place for those who will not be wearing these identification badges and sanctions against them?

Are appropriate physical security controls implemented to secure any ePHI stored in the information systems?
Does the facility plan document the rationale for the type of security controls implemented on the systems?
Does the facility plan document the security requirements of the systems along with the environment that the information system operates under?
Does the facility plan address the coordination of security activities such as assessments, maintenance on hardware and software, and contingency plan testing to minimize the operational impact on the information systems and workforce members?
Does the facility plan been reviewed and approved by the appropriate official prior to implementation?
Is the facility plan reviewed periodically to keep it updated when changes are made or if deficiencies are discovered through the security controls assessment?
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How To Have A Winning Facility Security Plan

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