Contingency Plan

5. Procedures

1. APPLICATIONS AND DATA CRITICALITY ANALYSIS

1.1 The Security Officer shall maintain an inventory of all systems and applications that process ePHI, categorized by criticality: - Critical: Systems essential for patient care and safety (e.g., EHR, pharmacy systems). Must be restored within [NUMBER] hours. - Important: Systems necessary for business operations but not immediately life-critical (e.g., practice management, billing). Must be restored within [NUMBER] hours. - Non-Critical: Systems that support operations but whose temporary unavailability does not affect patient care or compliance (e.g., marketing tools). Can tolerate [NUMBER] hours/days of downtime.

1.2 This analysis shall be updated annually and whenever new systems are deployed.

2. DATA BACKUP PLAN

2.1 All ePHI shall be backed up in accordance with the following schedule: - Critical systems: [FREQUENCY — e.g., real-time replication, daily incremental, weekly full] - Important systems: [FREQUENCY] - Non-critical systems: [FREQUENCY]

2.2 Backups shall be stored in a [LOCATION — e.g., off-site data center, cloud backup service, encrypted removable media stored at a separate physical location].

2.3 Backup media shall be encrypted using [ENCRYPTION STANDARD — e.g., AES-256].

2.4 Backup integrity shall be verified through automated verification checks and periodic test restores (at least [QUARTERLY/SEMI-ANNUALLY]).

2.5 The IT Manager shall maintain a Backup Log documenting: date and time of each backup, systems backed up, backup method, storage location, and verification results.

3. DISASTER RECOVERY PLAN

3.1 Recovery Priority: Systems shall be restored in order of criticality as defined in Section 1.

3.2 Recovery Procedures: The IT Manager shall maintain detailed, step-by-step restoration procedures for each critical and important system, including: contact information for vendors and cloud service providers, login credentials stored in a secured, accessible location (e.g., break-glass envelope or password vault), restoration procedures from backup, hardware replacement sources and procedures, and network reconfiguration steps.

3.3 Alternate Processing Site: If the primary facility is unavailable, [PRACTICE NAME] shall [DESCRIBE ALTERNATE ARRANGEMENTS — e.g., operate from a secondary office location, use cloud-based systems accessible from any location, activate a mutual aid agreement with another practice].

3.4 Communication Plan: During a disaster, the Practice Administrator shall notify: all workforce members via [METHOD], patients via [METHOD] if appointments or services are affected, business associates whose services are impacted, and regulatory authorities if required.

4. EMERGENCY MODE OPERATION PLAN

4.1 During an emergency that disrupts normal operations, the following procedures shall be followed to protect ePHI: - If ePHI systems are inaccessible, authorized workforce members may use paper-based processes with pre-printed forms stored at [LOCATION]. Paper records created during emergency mode shall be entered into electronic systems within [NUMBER] days of system restoration. - Physical security of ePHI shall be maintained at all times, even during evacuation. - Access to ePHI during emergency mode shall be limited to those workforce members who need it for patient care or system recovery. - If emergency access procedures are invoked (e.g., break-glass accounts), all such access shall be documented and reviewed after the emergency.

5. TESTING AND REVISION

5.1 The contingency plan shall be tested at least annually. Testing may include: tabletop exercises, backup restoration tests, full simulation of a disaster recovery scenario, or component testing of specific procedures.

5.2 Test results shall be documented, including: the scenario tested, participants, results, deficiencies identified, and corrective actions planned.

5.3 The plan shall be revised following any test that reveals deficiencies, after any actual emergency event, and after significant changes to systems or operations.

6. Roles & Responsibilities

Security Officer ([SECURITY OFFICER NAME]): Maintains the contingency plan. Conducts the applications and data criticality analysis. Coordinates testing. Ensures documentation is current.

IT Manager/Vendor ([IT CONTACT NAME]): Implements and monitors backup procedures. Maintains detailed recovery procedures. Performs restoration during disasters. Conducts backup verification tests.

Practice Administrator ([ADMINISTRATOR NAME]): Activates the contingency plan during an emergency. Manages the communication plan. Approves resource allocation for recovery. Makes decisions on alternate processing.

All Workforce Members: Know the location of emergency procedures. Follow emergency mode operation procedures. Report any issues during recovery to the Security Officer.

7. Review Schedule

This policy and the contingency plan shall be reviewed at least annually, after any actual emergency event, after any test that reveals deficiencies, and after significant changes to systems, facilities, or operations. The applications and data criticality analysis shall be updated concurrently.

8. Regulatory References

45 CFR § 164.308(a)(7)(i) — Contingency plan (Required) 45 CFR § 164.308(a)(7)(ii)(A) — Data backup plan (Required) 45 CFR § 164.308(a)(7)(ii)(B) — Disaster recovery plan (Required) 45 CFR § 164.308(a)(7)(ii)(C) — Emergency mode operation plan (Required) 45 CFR § 164.308(a)(7)(ii)(D) — Testing and revision procedures (Addressable) 45 CFR § 164.308(a)(7)(ii)(E) — Applications and data criticality analysis (Addressable) 45 CFR § 164.310(a)(2)(i) — Contingency operations (facility access) 45 CFR § 164.312(a)(2)(ii) — Emergency access procedure