Disaster recovery plan established
Plain English Translation
A documented disaster recovery plan must be established and implemented as needed, enabling the organization to restore any ePHI lost due to system failure, corruption, or disaster. The plan must be kept current and tested to ensure recovery objectives can be met in a real event.
Technical Implementation
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Required Actions (startup)
- Create a straightforward runbook documenting how to perform data restorations from your primary cloud or server backups.
- Assign clear ownership for executing the disaster recovery procedures during an emergency.
Required Actions (scaleup)
- Establish formal Recovery Time Objectives (RTO) and Recovery Point Objectives (RPO) based on an application criticality analysis.
- Perform scheduled tabletop exercises and sample live restorations to validate the technical accuracy of the recovery runbooks.
Required Actions (enterprise)
- Implement automated, infrastructure-as-code (IaC) driven disaster recovery failovers to geographically separated environments.
- Conduct full-scale, unannounced disaster recovery drills to evaluate team response times and automated failover efficacy.
A formal, documented set of procedures detailing how an organization will technically restore any loss of electronic protected health information (ePHI) following an emergency or system failure.
Yes, under the HIPAA Security Rule's Administrative Safeguards, establishing and implementing procedures to restore any loss of data is a required implementation specification.
It requires that covered entities and business associates establish (and implement as needed) procedures to restore any loss of data, which is formally referred to as a disaster recovery plan.
Organizations must document step-by-step technical procedures to retrieve ePHI from secure backups, rebuild compromised infrastructure, and verify data integrity before returning systems to production.
The plan should include roles and responsibilities, detailed system rebuild instructions, communication protocols, recovery time objectives (RTOs), and specific steps for restoring data from backups.
While HIPAA mandates periodic testing and revision of contingency plans, industry standard practice requires organizations to conduct disaster recovery drills or live restore tests at least annually.
A data backup plan focuses solely on creating and maintaining retrievable exact copies of ePHI, while the disaster recovery plan provides the operational steps to actually restore those backups.
Disaster recovery strictly focuses on restoring IT systems and lost data. Emergency mode operations focus on sustaining critical business and clinical processes while those IT systems remain down.
Yes, business associates are directly regulated by the HIPAA Security Rule and must implement all required contingency planning safeguards, including establishing a formal disaster recovery plan.
Maintain the written disaster recovery policy, document the results of periodic live restore tests or tabletop exercises, and retain records of any post-incident revisions made to improve the plan.
Disaster recovery evidence often becomes scattered across policies, restore logs, tabletop notes, and ticketing systems, making audit preparation harder than the control itself. Tools like WatchDog Security's Compliance Center can help centralize evidence, assign owners, track review dates, and map recovery documentation to HIPAA requirements.
Disaster recovery procedures can become outdated when infrastructure, applications, vendors, or recovery ownership changes. Tools like WatchDog Security's Policy Management can support version control, scheduled reviews, approval workflows, and acknowledgement tracking so teams know which recovery procedure is current.
| Version | Date | Author | Description |
|---|---|---|---|
| 1.0.0 | 2026-05-05 | WatchDog GRC Team | Initial publication |
