Health Insurance Portability and Accountability Act (HIPAA)
Security Rule Assessment Report

MediCare AI Platform

Assessment Period: January - March 2026

Generated by HAIEC Compliance Engine
Report ID: HIPAA-MCAI-2026Q1-001
Generated: February 16, 2026

1. Executive Summary

This report documents MediCare AI Platform's compliance with the HIPAA Security Rule (45 CFR §§ 164.302-164.318) for the assessment period January 1, 2026 through March 31, 2026. The assessment covers all required and addressable safeguards, with particular focus on AI-driven clinical decision support systems and ePHI protection.

Metric	Value
Total Safeguards Assessed	42 (18 Required, 24 Addressable)
Required Safeguards Implemented	18 (100%)
Addressable Safeguards Implemented	22 (92%)
Overall Compliance Score	95%
High-Risk Gaps	0

2. Scope and Covered Functions

Covered Entity: MediCare AI Platform (Healthcare Provider)

ePHI in Scope:

Patient demographics and medical records
Clinical notes and diagnostic reports
AI-generated treatment recommendations
Billing and insurance information

AI Systems Processing ePHI:

Clinical Decision Support System (CDSS) - risk stratification
Radiology AI - image analysis and anomaly detection
NLP-based clinical documentation assistant

3. Administrative Safeguards (§164.308)

§164.308(a)(1)(i) - Security Management Process (REQUIRED)

Status: IMPLEMENTED

Evidence:

Risk Analysis: Comprehensive risk assessment completed January 2026, covering all ePHI systems including AI platforms
Risk Management: Risk treatment plan with 12 identified risks, 10 mitigated, 2 accepted with Board approval
Sanction Policy: Employee disciplinary policy v2.3 includes HIPAA violations (3 incidents in Q1, all addressed)
Information System Activity Review: Weekly SIEM log reviews, quarterly audit log analysis

HAIEC Verification: Risk assessment documentation reviewed, risk register validated, sanction policy enforcement confirmed via HR records.

§164.308(a)(3)(i) - Workforce Security (REQUIRED)

Status: IMPLEMENTED

Evidence:

Authorization/Supervision: Role-based access control, 8 roles defined, quarterly access reviews
Workforce Clearance: Background checks for all employees with ePHI access (100% completion)
Termination Procedures: Access revocation within 1 hour of termination (automated via Okta)

§164.308(a)(4)(i) - Information Access Management (REQUIRED)

Status: IMPLEMENTED

Evidence:

Access Authorization: Formal access request process, manager approval required
Access Establishment: Principle of least privilege enforced, AI model access restricted to ML Engineering team
Access Modification: Q1 2026: 8 access modifications, all documented with justification

§164.308(a)(5)(i) - Security Awareness and Training (REQUIRED)

Status: IMPLEMENTED

Evidence:

Annual HIPAA training (100% completion, average score: 94%)
AI-specific module: "Protecting ePHI in Machine Learning Workflows"
Phishing simulations: Monthly, 3% click rate (industry avg: 11%)
Security reminders: Quarterly newsletters, Slack security tips

§164.308(a)(6)(i) - Security Incident Procedures (ADDRESSABLE)

Status: IMPLEMENTED

Evidence:

Incident response plan v3.1 (tested quarterly, last test: February 2026)
Q1 2026: 2 security incidents, both contained within 4 hours, no ePHI breach
Incident log maintained, root cause analysis for all incidents
HHS breach notification procedure documented (never triggered)

§164.308(a)(7)(i) - Contingency Plan (REQUIRED)

Status: IMPLEMENTED

Evidence:

Data Backup: Daily automated backups, 30-day retention, encrypted at rest
Disaster Recovery: RTO: 4 hours, RPO: 1 hour, tested annually (last: December 2025)
Emergency Mode: Manual failover procedures documented, tested quarterly
Testing: Tabletop exercise Q1 2026, full DR test scheduled Q2 2026

§164.308(a)(8) - Evaluation (ADDRESSABLE)

Status: IMPLEMENTED

Evidence:

Annual HIPAA compliance evaluation (this report)
Quarterly internal audits (Q1 2026: 3 audits, 2 minor findings, both remediated)
External audit: Last conducted October 2025 by Acme Compliance, no major findings

4. Physical Safeguards (§164.310)

§164.310(a)(1) - Facility Access Controls (REQUIRED)

Status: IMPLEMENTED

Evidence:

Contingency Operations: Backup facility identified (AWS US-East-2)
Facility Security Plan: Badge access system, 24/7 security, visitor logs
Access Control: Server room restricted to IT staff (5 authorized users)
Validation: Quarterly access log reviews, no unauthorized access detected

§164.310(b) - Workstation Use (REQUIRED)

Status: IMPLEMENTED

Evidence:

Workstation use policy v1.8 (prohibits ePHI on personal devices)
Privacy screens mandatory for workstations in open areas
Auto-lock after 5 minutes of inactivity
Clean desk policy enforced (monthly audits)

§164.310(c) - Workstation Security (REQUIRED)

Status: IMPLEMENTED

Evidence:

Full disk encryption (BitLocker/FileVault) on all workstations
Endpoint protection (CrowdStrike) deployed, 100% coverage
USB ports disabled on workstations with ePHI access

§164.310(d)(1) - Device and Media Controls (ADDRESSABLE)

Status: IMPLEMENTED

Evidence:

Disposal: Certified data destruction vendor (Iron Mountain), certificates retained
Media Re-use: Secure wipe procedures (NIST 800-88 compliant)
Accountability: Asset inventory maintained, quarterly reconciliation
Data Backup: Backup media encrypted, stored offsite (AWS S3 Glacier)

5. Technical Safeguards (§164.312)

§164.312(a)(1) - Access Control (REQUIRED)

Status: IMPLEMENTED

Evidence:

Unique User ID: All users have unique credentials, no shared accounts
Emergency Access: Break-glass accounts for emergency access, logged and reviewed
Auto Logoff: 15-minute inactivity timeout on all ePHI systems
Encryption: ePHI encrypted at rest (AES-256) and in transit (TLS 1.3)

§164.312(b) - Audit Controls (REQUIRED)

Status: IMPLEMENTED

Evidence:

Comprehensive audit logging: authentication, ePHI access, modifications, deletions
Logs retained for 7 years (HIPAA requirement: 6 years)
SIEM deployment (Splunk) with real-time alerting
AI model access logged: training data access, inference requests, model updates

§164.312(c)(1) - Integrity (REQUIRED)

Status: IMPLEMENTED

Evidence:

Mechanism to Authenticate: SHA-256 checksums for all ePHI data transfers
Database integrity constraints enforced
AI model versioning with cryptographic signatures
Tamper detection: File integrity monitoring (FIM) on all ePHI systems

§164.312(d) - Person or Entity Authentication (ADDRESSABLE)

Status: IMPLEMENTED

Evidence:

Multi-factor authentication (MFA) required for all ePHI access
MFA enrollment: 100% (enforced via Okta)
Password policy: 12+ characters, complexity requirements, 90-day rotation
Biometric authentication for mobile ePHI access (Face ID/Touch ID)

§164.312(e)(1) - Transmission Security (ADDRESSABLE)

Status: IMPLEMENTED

Evidence:

Integrity Controls: TLS 1.3 for all ePHI transmissions
Encryption: End-to-end encryption for patient portal communications
VPN required for remote access to ePHI systems
Email encryption (S/MIME) for ePHI-containing emails

6. AI-Specific HIPAA Considerations

AI System	HIPAA Safeguard	Implementation
Clinical Decision Support	Access Control (§164.312(a))	Role-based access, MFA enforced, audit logging
Radiology AI	Integrity (§164.312(c))	Model versioning, SHA-256 signatures, tamper detection
NLP Documentation Assistant	Transmission Security (§164.312(e))	TLS 1.3, encrypted API calls, no ePHI in logs
All AI Systems	Minimum Necessary (§164.502(b))	Data minimization: only necessary ePHI used for training/inference

7. Gaps and Remediation

Safeguard	Gap	Remediation Plan	Target Date
§164.308(a)(1)(ii)(B) - Risk Management	AI bias risk not formally assessed in risk register	Add AI bias as risk category, conduct bias assessment for CDSS	April 30, 2026
§164.312(e)(2)(ii) - Encryption	Backup tapes not encrypted (addressable, alternative: physical security)	Implement backup encryption or document equivalent physical safeguards	May 15, 2026

8. Cryptographic Verification

Report Hash (SHA-256):
c9f2e5b8d1a7f4c3e0b9d6f3a2c8e5b2d9f6a3c0e7b4d1f8a5c2e9b6d3f0a7c4

Signed By: HAIEC Compliance Engine v2.1.0
Signature Timestamp: 2026-02-16T17:40:00Z
Verification URL: https://haiec.com/verify/HIPAA-MCAI-2026Q1-001

Health Insurance Portability and Accountability Act (HIPAA)Security Rule Assessment Report

1. Executive Summary

2. Scope and Covered Functions

3. Administrative Safeguards (§164.308)

§164.308(a)(1)(i) - Security Management Process (REQUIRED)

§164.308(a)(3)(i) - Workforce Security (REQUIRED)

§164.308(a)(4)(i) - Information Access Management (REQUIRED)

§164.308(a)(5)(i) - Security Awareness and Training (REQUIRED)

§164.308(a)(6)(i) - Security Incident Procedures (ADDRESSABLE)

§164.308(a)(7)(i) - Contingency Plan (REQUIRED)

§164.308(a)(8) - Evaluation (ADDRESSABLE)

4. Physical Safeguards (§164.310)

§164.310(a)(1) - Facility Access Controls (REQUIRED)

§164.310(b) - Workstation Use (REQUIRED)

§164.310(c) - Workstation Security (REQUIRED)

§164.310(d)(1) - Device and Media Controls (ADDRESSABLE)

5. Technical Safeguards (§164.312)

§164.312(a)(1) - Access Control (REQUIRED)

§164.312(b) - Audit Controls (REQUIRED)

§164.312(c)(1) - Integrity (REQUIRED)

§164.312(d) - Person or Entity Authentication (ADDRESSABLE)

§164.312(e)(1) - Transmission Security (ADDRESSABLE)

6. AI-Specific HIPAA Considerations

7. Gaps and Remediation

8. Cryptographic Verification

Health Insurance Portability and Accountability Act (HIPAA)
Security Rule Assessment Report