Sample HIPAA Security Risk Analysis
A proof-of-work example showing how VALO can document healthcare security risk, safeguard gaps, ownership, and remediation priorities.
This is not a client case study. The organization, systems, findings, metrics, and risk values below are fictional and exist only to demonstrate the structure and level of detail of a VALO deliverable.
Executive context
Example organization: Lakeside Behavioral Health, a fictional 42-employee outpatient behavioral-health practice using a cloud EHR, Microsoft 365, managed endpoints, a small office network, telehealth, and eight business associates.
Objective: identify reasonably anticipated risks to ePHI, document safeguard gaps, assign risk ownership, and produce a practical remediation plan.
Sample findings
| ID | Finding | Risk | Safeguard area | Recommended action |
|---|---|---|---|---|
| H-01 | ePHI inventory does not fully document all storage locations, exports, telehealth workflows, and local device handling. | High | Risk analysis / asset visibility | Complete an ePHI data-flow and asset inventory; assign ownership and review it annually and after material changes. |
| H-02 | MFA is not consistently enforced for all remote and privileged access paths. | High | Access control / authentication | Enforce MFA, remove legacy paths, document emergency access, and validate privileged-account separation. |
| H-03 | Backup restoration is assumed but has not been demonstrated through a documented recovery test. | High | Contingency planning | Perform a recovery exercise, capture evidence, define recovery ownership, and track deficiencies. |
| H-04 | Business associate oversight is inconsistent and security evidence is not tracked centrally. | Moderate | Third-party risk | Maintain a business-associate inventory, BAA status, risk tier, security evidence, renewal dates, and remediation items. |
| H-05 | Known security findings lack target dates and formal risk acceptance. | Moderate | Security management process | Use a risk register with owner, due date, treatment, exception, residual risk, and leadership review. |
Sample remediation roadmap
0–30 days
- Complete ePHI inventory and data flows.
- Enforce MFA for privileged and remote access.
- Assign owners to all high risks.
- Document critical business associates and BAA status.
31–60 days
- Run backup restoration test.
- Review privileged access and account lifecycle.
- Formalize risk acceptance and exception process.
- Update incident contacts and escalation paths.
61–90 days
- Run a security incident tabletop.
- Validate remediation evidence.
- Review vendor security evidence.
- Present residual risks to leadership.
What the client would receive
Executive risk analysis report, HIPAA-aligned risk register, safeguard-gap summary, third-party observations, prioritized remediation roadmap, evidence requests, and a leadership readout. The engagement does not represent a legal opinion, certification, or regulatory guarantee.
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