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Documentation/ HIPAA/ Administrative Safeguards

HIPAA COMPLIANCE FRAMEWORK

Administrative Safeguards

Documents administrative controls for workforce access, risk management, sanctions, contingency planning, incident response, training, and policy governance.

Privacy, security, legal, and Provider responsibility notice

These pages describe True Care System functionality and operating expectations. They do not replace Provider policies, legal advice, risk analysis, workforce training, contracts, or regulatory obligations. Use minimum-necessary access and protect PHI in screenshots, exports, tickets, messages, and reports.

Purpose

Documents administrative controls for workforce access, risk management, sanctions, contingency planning, incident response, training, and policy governance.

Core Requirements

Security Management Process

Identify risks, apply safeguards, document decisions, and track corrective action.

Workforce Security

Authorize, supervise, review, and terminate access based on role and Provider responsibility.

Information Access Management

Use role-based access, least privilege, minimum necessary, and separation of duties.

Security Awareness

Train users on passwords, devices, phishing, PHI handling, reporting, and secure workflows.

Contingency Planning

Maintain backup, disaster recovery, emergency operation, and testing procedures.

Operational Review Checklist

Review AreaExpectation
Provider ScopeConfirm the correct Provider before viewing, changing, exporting, or investigating records.
Authorized PurposeConfirm the user’s role, approved purpose, and minimum-necessary scope.
EvidenceRetain relevant timestamps, actors, targets, identifiers, IP addresses, devices, reasons, and results.
EscalationEscalate unexpected, denied, suspicious, cross-Provider, bulk, or high-risk activity.
DocumentationRecord decisions, corrective action, validation, and required follow-up.

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