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HIPAA · 15 RECURRING ACTIVITIES

HIPAA Compliance Calendar — recurring §164 obligations, scheduled

OCR investigations almost always start the same way: 'show us your most recent risk analysis.' If yours is more than 12 months old, you're already in trouble. This calendar maps every recurring HIPAA Security + Privacy Rule activity to a specific §164 reference.

Cadence mix:1× Weekly2× Monthly2× Quarterly1× Every 6 months7× Annually2× Event-triggered
Who this is for
  • Covered entities (providers, plans, clearinghouses) and Business Associates
  • Security Officers / Privacy Officers running active HIPAA programs
  • Healthcare SaaS vendors operating under signed BAAs
Typical effort
Plan for a designated Security Officer + Privacy Officer (often combined). Major effort: annual risk analysis (40+ hrs).

The calendar

Weekly (1)

Audit log review — failed access + impermissible disclosure flags
Audit Controls
Sample audit logs from EHR / database / S3 access logs. Investigate anomalies.
Reference
§164.312(b)
Owner
Security officer
Effort
1–2 hrs
Evidence
Log review record

Monthly (2)

Termination access removal verification
Workforce
Cross-check HR off-boarding list against system disablements within target SLA (typ. 24 hrs).
Reference
§164.308(a)(3)(ii)(C)
Owner
HR + IT
Effort
1 hr
Evidence
Termination access log
Patch + vulnerability scan
Vulnerability
OS / DB / app patching. Document any deferred patches with risk acceptance.
Reference
§164.308(a)(1)(ii)(B)
Owner
IT
Effort
4 hrs
Evidence
Patch + scan reports

Quarterly (2)

Workforce access review (role-based)
Workforce Access
Manager certifies users still need their level of PHI access. Remove or downgrade as needed.
Reference
§164.308(a)(4)
Owner
Manager + IT
Effort
3–4 hrs
Evidence
Signed access review
Sanctions log review
Sanctions
Review any workforce HIPAA violations + sanctions applied. Required documentation.
Reference
§164.308(a)(1)(ii)(C)
Owner
Privacy officer + HR
Effort
1–2 hrs
Evidence
Sanctions log

Every 6 months (1)

Contingency plan test (data backup / disaster recovery / emergency mode)
Contingency
Restore a sample backup; failover one critical service; document.
Reference
§164.308(a)(7)(ii)(D)
Owner
IT + Security
Effort
8–16 hrs
Evidence
Contingency test report

Annually (7)

HIPAA Security Rule risk analysis
Risk
Required, accurate, thorough — covers all ePHI flows (Cloud + on-prem + endpoint + BAAs). Output: documented risks + likelihood + impact.
Reference
§164.308(a)(1)(ii)(A)
Owner
Security officer
Effort
40–80 hrs
Evidence
Risk analysis report
Risk management plan update
Risk
Address risks identified — implement, mitigate, accept; track residual risk.
Reference
§164.308(a)(1)(ii)(B)
Owner
Security officer
Effort
16 hrs
Evidence
Risk management plan
Workforce HIPAA training
Workforce
Required for every workforce member — Privacy + Security awareness; new hires within reasonable time; updated when material change.
Reference
§164.530(b), §164.308(a)(5)
Owner
Privacy officer + HR
Effort
4 hrs admin
Evidence
Training completion records
Policies + procedures review
Policies
Every Security + Privacy Rule policy reviewed and updated as needed. 6-year retention required.
Reference
§164.316(b)
Owner
Privacy + Security officers
Effort
8–16 hrs
Evidence
Updated policy library
BAA inventory + renewal review
BAA
Every Business Associate has a current, valid BAA covering PHI use + breach notification. Refresh expiring agreements.
Reference
§164.308(b), §164.502(e)
Owner
Privacy officer + Legal
Effort
8–12 hrs
Evidence
BAA register + renewals
Notice of Privacy Practices review
Privacy
NPP must be current; redistribute on material change; available on website + at point of care.
Reference
§164.520
Owner
Privacy officer
Effort
4 hrs
Evidence
NPP version + posting evidence
Periodic technical + nontechnical evaluation
Evaluation
Required §164.308(a)(8) — confirm policies + procedures continue to meet the Security Rule. Often combined with annual risk analysis.
Reference
§164.308(a)(8)
Owner
Security officer
Effort
16 hrs
Evidence
Evaluation report

Event-triggered (2)

Breach risk assessment + notification
Breach
Any impermissible PHI use/disclosure: 4-factor risk assessment; if breach, notify individuals within 60 days, HHS, and (if 500+) media.
Reference
§164.402, §164.404, §164.408, §164.410
Owner
Privacy officer + Legal
Effort
Variable
Evidence
Breach risk assessment + notice records
New Business Associate onboarding
BAA
Signed BAA before any PHI shared. Vendor security review proportionate to risk.
Reference
§164.308(b), §164.502(e)
Owner
Privacy officer + Procurement
Effort
4–8 hrs
Evidence
Signed BAA + due diligence

Pitfalls — where teams actually fail

Want this calendar mapped to YOUR controls?

Drop your existing HIPAA policy or upload a draft — ComplianceIQ scores it against the framework and produces a 0–100 audit, gap-by-gap with the cadence work you're missing.

Run free HIPAA audit See readiness checklist

What happens when the cadence slips — real HIPAA actions

$16M
Anthem Inc. · 2018
$6.85M
Premera Blue Cross · 2020

FAQ

Is the annual HIPAA risk analysis a strict regulatory requirement?
Yes. §164.308(a)(1)(ii)(A) requires an accurate and thorough assessment of risks to ePHI. OCR has fined entities specifically for not having a current, comprehensive risk analysis.
How often must HIPAA training happen?
On hire (within reasonable time), and any time there's a material change to policies/procedures. Annual training is the prevailing best practice and what auditors look for.
Do Business Associates need to follow this calendar?
Yes — the HIPAA Security Rule applies in full to BAs since 2013 (Omnibus Rule). The risk analysis, workforce training, audit-log review, and contingency plan obligations all apply identically.
Does this calendar cover the new HIPAA Security Rule update (2024–2025 NPRM)?
Items here align with the long-standing Final Rule. The proposed 2024 NPRM strengthens technical safeguards (mandatory MFA, encryption, vulnerability scans, network segmentation, written contingency plans) — items already in this calendar align with that direction.

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