Risk Assessment and Compliance Services

Protect patient data, satisfy MIPS and avoid costly fines and lost business.

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Why Risk Assessments?

Risk Analysis Requirements under the Security Rule

The Security Management Process standard in the Security Rule requires organizations to “[i]mplement policies and procedures to prevent, detect, contain, and correct security violations.” (45 C.F.R. § 164.308(a)(1).)

Risk analysis is one of four required implementation specifications that provide instructions to implement the Security Management Process standard. Section 164.308(a)(1)(ii)(A) states:

RISK ANALYSIS – Required.  Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the [organization].” 1

Satisfy MIPS Performance Requirements:

Merit-Based Incentive Payment System (MIPS) Advancing Care Information Performance Category Transition Measure:

Objective: Protect Patient Health Information
Measure: Security Risk Analysis
Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164/308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the MIPS eligible clinician’s risk management process.

Cyber Trust Alliance Risk Assessment Framework for HIPAA Security Privacy and Breach Compliance.

Policies and Procedures

Perform a gap analysis of required policies and procedures – based on the Office of Civil Rights (OCR) protocol.

Business Associates

Review Business Associate Agreements with vendors and let CTA assess and review their compliance for you.


Assess and document the hardware, software, configuration, policies and practices that make up the foundation of your business.


Let CEBA train your team and track and record the results for you.

Vulnerability Assessment

CTA scans your network for vulnerabilities on a quarterly basis and provides reports for remediation.

Phishing Assessment

Phishing assessments reveal how susceptible your team is to social engineering attacks that can lead to data breaches. CTA performs these on a quarterly basis.

Policy Management

CEBA requires clients to review and approve all policies on an annual basis, which also triggers a review and acceptance by all employees to ensure all are aware of current policies.

Physical Security

Let our audit team accompany you on a tour of your facility via our Tel Assessment appliance. Live streaming video and photographs allow us to assess and document the experience as part of the assessment process.

“It is critical that entities take a comprehensive and thorough approach to assessing and addressing the risk to all of the protected health information they maintain. Entities must have comprehensive policies and procedures for compliance with the HIPAA Rules, but also the policies and procedures must be clearly communicated to and implemented by all workforce members”

Jocelyn Samuels

Former Director Office of Civil Rights

Let’s Make Things Happen

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Christopher Canada


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