HIPAA (45 CFR Part 164) 164.312(a)(2)(ii) — Access Control - Emergency Access Procedure

What this control requires

Establish (and implement as needed) procedures for obtaining necessary electronic protected health information during an emergency.

In plain English

Establish (and implement as needed) procedures for obtaining necessary electronic protected health information during an emergency. In practice, this means you can prove you security security-level controls on a defined cadence.

Why it matters

HIPAA non-compliance is a strict-liability matter: OCR civil monetary penalties are assessed per-record per-violation (up to USD 1.9 million per identical-violation calendar year as of 2024), and willful neglect can trigger criminal referral.

What an auditor looks for

HHS OCR investigators and SOC-2+HIPAA auditors look for the specific 45 CFR § citation, whether the safeguard is required vs addressable (and if addressable, the documented decision), the implementation specification, the workforce member responsible, and the records that show it runs.

Within Security Rule, the assessor will trace your implementation back to the catalogue reference (§ 164.312(a)(2)(ii)) and look for objective evidence on the latest two assessment cycles.

How to implement

Policy Management

Docs. Keep each policy in version-controlled Markdown alongside the code that implements it; ship a signed PDF snapshot at each annual review and link the SHA into the SoA.

Operational checklist

• Security. Document the trigger, the owner and the cadence.
• Information. Document the trigger, the owner and the cadence.
• Access Control. Document the trigger, the owner and the cadence.
• Policy. Document the trigger, the owner and the cadence.
• Scope: security, management, - emergency access procedure, procedures, policy.

Evidence to collect

• Policy Document. A signed and version-controlled policy / standard / procedure document.

Signed policy or standard documents the safeguard. Focus: Access Control - Emergency Access Procedure.

Common pitfalls

• Policies that no engineer has read; the version in Confluence drifts from the version that's actually being enforced.

How it maps to other frameworks

Computed from shared tags, control component and key-operation subjects — handy when you are reconciling controls across an audit.

• BSI C5:2020 SP-01 — Documentation, communication and provision of policies and instructions
• NIST SP 800-171 Rev. 3 3.1.5 — Least Privilege
• NIST SP 800-53 Rev. 5 CP-1 — Policy And Procedures
• ISO/IEC 27001:2022 A.5.1 — Policies for information security
• SOC 2 (2017 TSC) CC2.3 — External Communication on Internal Control Matters

Related controls in HIPAA (45 CFR Part 164)

• § 164.308(a)(4)(ii)(A) — Information Access Management - Isolating Healthcare Clearinghouse Functions
• § 164.308(a)(4)(ii)(B) — Information Access Management - Access Authorization
• § 164.310(a)(1) — Facility Access Controls
• § 164.308(a)(5)(ii)(B) — Security Awareness, Training, and Tools - Protection from Malicious Software
• § 164.308(a)(5)(ii)(C) — Security Awareness, Training, and Tools - Log-in Monitoring
• § 164.308(a)(5)(ii)(D) — Security Awareness, Training, and Tools - Password Management

References

• U.S. HHS Office for Civil Rights — HIPAA (45 CFR Part 164)
• Catalogue identifier: § 164.312(a)(2)(ii)

Topics: governance riskpolicy management