September 14, 2020

What is HIPAA compliance?

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If you’ve interacted with any health-related service in the last 20-plus years, you’ve heard of HIPAA and the need to be HIPAA compliant. For companies working in or with the healthcare industry, HIPAA compliance is the cornerstone of a strong security posture.

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Are you in tune with what it takes to gain and maintain HIPAA compliance? Why is HIPAA compliance so important, and who needs to be HIPAA compliant? And what happens if an organization isn’t HIPAA compliant? Read on for answers to all these questions about HIPAA compliance and becoming compliant.

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Let’s start from the top: When did HIPAA compliance start?

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‍HIPAA stands for the Healthcare Insurance Portability and Accountability Act, which was signed into law on August 21, 1996. HIPAA’s high-level goal is to keep patients’ protected health information (PHI) — any individually identifiable health information — safe and secure, whether it exists in a physical or electronic form.

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HIPAA was passed to improve the portability and accountability of health insurance coverage for employees moving between jobs. An additional goal of HIPAA include providing coverage for employees with pre-existing medical conditions and simplifying the administration of health insurance.

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If your company works in the healthcare industry or is considering working with healthcare clients, it is important to have an understanding of HIPAA. It's also crucial you understand how to become HIPAA compliant and how to stay up to date on compliance.

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HIPAA applies to organizations known as covered entities and business associates. Covered entities HIPAA applies to include health care providers like:

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Doctors
Clinics
Psychologists
Health plans
Health insurance companies
Government healthcare programs
Health care clearinghouses

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Business associates are people or entities performing activities that involve the use or disclosure of protected health information on behalf of or in service to a covered entity. Business associates could include third party administrators assisting a health plan with claims processing, SaaS healthcare solutions such as telemedicine technologies and mobile health apps, and more.

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Why is HIPAA compliance so important?

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Before HIPAA was instituted, there was not a common set of accepted security standards or requirements for the protection of health information in the healthcare industry. HIPAA put in place requirements to ensure that healthcare organizations are actively safeguarding patient data — and also instituted repercussions for those organizations that fail to be HIPAA compliant.

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Technologies have evolved — and continue to evolve — in the years since HIPAA took effect and HIPAA compliance was put in place. Over time, the healthcare industry as a whole has been moving away from keeping and collecting data and information on paper, moving instead toward using electronic information systems to conduct a wide range of industry functions. These functions include both in the clinical delivery of care and in its administration.

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With more and more protected health information flowing through the many computerized systems and processes of covered entities and their business associates — from electronic health records and pharmacy and laboratory information, to computerized physician order entry (CPOE), by which healthcare providers use computers to directly enter medical orders — HIPAA compliance and the diligent protection of patient PHI only continues to increase in importance. New technology is always coming into play to manage and secure data in the healthcare industry; companies must be able to integrate and work with new technologies while maintaining the safety and security of patient PHI.

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In order to ensure that your company is in compliance with HIPAA, your organization should build and implement a holistic data protection strategy that encompasses all areas of HIPAA compliance while ensuring the security and availability of PHI, and maintaining the trust of patients and those people and organizations with whom you do business.

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So, What is HIPAA compliance?

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There are a number of HIPAA rules that must be adhered to in order to ensure HIPAA compliance. The HIPAA Security Rule, instituted in 2005, is key among these rules. HIPAA Security Rules specify safeguards to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI).

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The Security Rule articulates three types of security safeguards:

Administrative
Physical
Technical

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Security safeguards are required for a company to be in HIPAA compliance.

Administrative safeguards include a company’s performance of risk analysis as a part of their security management processes.

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Examples include:

Evaluating the likelihood and impact of potential risks to ePHI
Implementing security measures to address identified risks
Documenting security measures to be taken
Maintaining continuous and appropriate security protections

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Administrative safeguards also include:

Designation of an official representative or team responsible for HIPAA security policies and procedures
Implementing role-based access to ePHI
Providing employee training
Regularly evaluating how a company’s policies and procedures are meeting the Security Rule

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Physical safeguards include limiting and managing physical access to facilities while enabling authorized access, and implementing policies and procedures for access to and use of workstations and electronic media. Physical safeguards to become HIPAA compliant also include regarding transfer, removal, disposal, and reuse of electronic media, in order to protect ePHI.

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Technical safeguards include the implementation of ePHI access control policies, audit control mechanisms for the recording and examination of access and activity in systems interacting with ePHI.

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To be HIPPA compliant, you'll also need integrity controls to ensure and confirm that ePHI is not improperly altered or destroyed, and transmission security measures protecting against unauthorized ePHI access while ePHI is in transmission over a network.

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In addition to implementing these safeguards for the protection of sensitive patient information, organizations working or interacting with patient PHI must now complete annual self-audits assessing their privacy and security practices to ensure that they are in line with current HIPAA standards, and should vet the vendors with whom they work.

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Who needs to maintain compliance with HIPAA? And what happens if an organization is not in compliance with HIPAA?

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The U.S. government passed the HITECH (Health Information Technology for Economic and Clinical Health) Act in 2009 to further encourage use of electronic health records. The HITECH Act also increased penalties for organizations in violation of HIPAA, and introduced the Breach Notification Rule.

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The Breach Notification Rule requires that breaches of unsecured protected health information must be communicated to affected individuals, the U.S. Department of Health and Human Services (HHS). In some cases breaches may even need to be reported to the media.

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As of 2020, HIPAA requires that breaches affecting fewer than 500 people, known as Minor Breaches, must be reported by the end of the calendar year to HHS and the affected individuals. Breaches affecting more than 500 people, known as Meaningful Breaches, must be reported within 60 days to HHS, the affected individuals, and the media. Meaningful Breaches reported to HHS are added to its Breach Notification Portal, a permanent archive and searchable database of HIPAA violations going back to 2009.

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A data breach is not automatically a HIPAA violation HIPAA violation is defined as a failure to comply with HIPAA standards and provisions. If an organization’s compliance program compromises the security and integrity of PHI or ePHI, then the organization is in violation of HIPAA.

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Thus a data breach resulting from an incomplete or ineffective HIPAA compliance program becomes a HIPAA violation. Organizations in violation of HIPAA risk compromising sensitive patient information — and facing financial and other penalties as a result.

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Violations and data breaches can be extremely costly, from steep monetary fines to the costs of communicating breach notifications and mitigating subsequent damages, to the possibility of criminal prosecution.

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How can my organization sustain our HIPAA compliance?

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One of the top challenges in HIPAA compliance is finding a way to continuously stay compliant despite changes to your systems and staff. To prevent costly compliance gaps, follow these top tips.

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Maintain Thorough Activity Logs - Have protocols and processes in place to make sure your IT staff has a detailed log of anything pertaining to PHI and where it goes. Along with this, find a way to monitor those logs and keep an eye out for security risks among this activity.
Lock Down Log-Ins - Maintain strict rules and requirements for passwords organization-wide and enforce these policies for every employee or contractor.
Layer Your Security - The best security takes a multi-layered approach to keep breaches at bay and make it easier to detect threats before they become problems. Layer security strategies like log-ins, multi-factor authentication, encryption, and more.

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Other recent HIPAA compliance updates to be aware of:

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New laws and amendments to laws can happen at any time and it’s up to your organization to keep track and make sure you’re following the current HIPAA and privacy laws. Just in the past few years, there have been multiple changes and new laws, such as:

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2020 CARES Act
2021 HIPAA Safe Harbor Law
21st Century Cures Act
HIPAA Civil Monetary Penalty Overturned

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Recent HIPAA updates under consideration have included potential changes to HIPAA compliance and related regulations with the goal of protecting the privacy of patients seeking treatment for substance abuse disorders. In the context of the opioid epidemic, there have been calls to make changes that would enable clinicians to view full medical records, including records related to substance abuse disorders.

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Access to these medical records would allow for treatment decisions to be informed by a patient’s full health history. With the passage of the Coronavirus Aid, Relief, and Economic Security (CARES) Act in 2020, healthcare providers’ ability to share records of individuals with substance abuse disorders has been expanded. At the same time, the CARES Act has tightened requirements around confidentiality breaches.

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Vanta is here to help your company build a holistic security compliance program that will support your ongoing HIPAA compliance. Vanta provides a set of security and compliance tools that scan, verify, and secure a company’s IT systems and processes.

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Vanta also offers a suite of tools streamlining the non-technical components of security tracking and audit preparation, so that gathering, maintaining, and consolidating audit evidence is easier for both your company and your auditor. Vanta is “security in a box” for technology companies, trusted by hundreds for automated security and compliance.

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Pre-work for your SOC 2 compliance

Choose the right type of SOC 2 report:

A SOC 2 Type 1 report assesses how your organization aligns with the security controls and policies outlined in SOC 2

A SOC 2 Type 2 report has all the components of a Type 1 report with the addition of testing your controls over a period of time

The correct report will depend on the requirements or requests of the client or partner that has requested a SOC 2 report  
from you

Determine the framework for your SOC 2 report. Of the five Trust Service Criteria in SOC 2, every organization needs to comply with the first criteria (security), but you only need to assess and document the other criteria that apply. Determining your framework involves deciding which Trust Service Criteria and controls are applicable to your business using our Trust Service Criteria Guide.

Estimate the resources you expect to need. This will vary depending on how closely you already align with SOC 2 security controls, but it can include several costs such as:

Compliance software

Engineers and potentially consultants

Security tools, such as access control systems

Administrative resources to draft security policies

Auditing for your compliance certification

Obtain buy in from your organization leadership to provide the resources your SOC 2 compliance will need.

Work toward SOC 2 compliance

Begin with an initial assessment of your system using compliance automation software to determine which necessary controls and practices you have already implemented and which you still need to put in place.

Review your Vanta report to determine any controls and protocols within the “Security” Trust Service Criteria that you do not yet meet and implement these one by one. These are multi-tiered controls across several categories of security, including:

CC1: Control Environment

CC2: Communication and Information

CC3: Risk Assessment

CC4: Monitoring Activities

CC5: Control Activities

CC6: Logical and Physical Access Controls

CC7: System Operations

CC8: Change Management

CC9: Risk Mitigation

Using Vanta’s initial assessment report as a to-do list, address each of the applicable controls in the other Trust Services Criteria that you identified in your initial framework, but that you have not yet implemented.

Using Vanta’s initial assessment report, draft security policies and protocols that adhere to the standards outlined in SOC 2.  

Vanta’s tool includes thorough and user-friendly templates to make this simpler and save time for your team.

Run Vanta’s automated compliance software again to determine if you have met all the necessary criteria and controls for your SOC 2 report and to document your compliance with these controls.

Complete a SOC 2 report audit

Select and hire an auditor affiliated with the American Institute of Certified Public Accountants (AICPA), the organization that developed and supports SOC 2.

Complete a readiness assessment with this auditor to determine if you have met the minimum standards to undergo a full audit.

If your readiness assessment indicates that there are SOC 2 controls you need to address before your audit, complete these requirements. However, if you have automated compliance software to guide your preparations and your SOC 2 compliance, this is unlikely.

Undergo a full audit with your SOC 2 report auditor. This may involve weeks or longer of working with your auditor to provide the documentation they need. Vanta simplifies your audit, however, by compiling your compliance evidence and documentation into one platform your auditor can access directly.

When you pass your audit, the auditor will present you with your SOC 2 report to document and verify your compliance.

Maintain your SOC 2 compliance annually

Establish a system or protocol to regularly monitor your SOC 2 compliance and identify any breaches of your compliance, as this can happen with system updates and changes.

Promptly address any gaps in your compliance that arise, rather than waiting until your next audit.

Undergo a SOC 2 re-certification audit each year with your chosen SOC 2 auditor to renew your certification.

Download this checklist for easy reference

Download now

Prioritizing Your Security and Opening Doors with SOC 2 Compliance

Information security is a vital priority for any business today from an ethical standpoint and from a business standpoint. Not only could a data breach jeopardize your revenue but many of your future clients and partners may require a SOC 2 report before they consider your organization. Achieving and maintaining your SOC 2 compliance can open countless doors, and you can simplify the process with the help of the checklist above and Vanta s compliance automation software. Request a demo today to learn more about how we can help you protect and grow your organization.

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Request a demo

Pre-work for your ISO 42001 compliance

Understand ISO 42001 requirements

Decide on what is the scope of the AIMS

Familiarize yourself with key AI concepts, principles, and lifecycle based on ISO frameworks

Determine if you are a provider, developer, or user of AI systems

Perform initial gap analysis

Using Vanta, asses your in-scope ISO 42001 controls

Identify areas of requirement, development, or adjustment

Secure top management support

Present a business case highlighting the benefits of ISO 42001 certification

Define roles and responsibilities for top management in AIMS implementation

Involve various department heads in the analysis to ensure comprehensive coverage

Work for your ISO 42001 compliance

Appoint a Project Manager

Designate an owner for the ISO 42001 implementation project

Develop a project plan

Outline steps, timelines, and resources needed for AIMS implementation

Integrate the AIMS implementation project within existing organizational processes

Establish the AIMS framework

Define the scope and objectives of the AIMS within the organization

Develop and document AI policies and risk management processes

Based on gap analysis, implement necessary controls for AIMS

Ensure integration of AIMS with other management systems and requirements

Create an AIMS statement of applicability (SOA)

Promote competence and awareness

Conduct training for stakeholders on AI concepts and ISO 42001 requirements

Raise awareness about the importance and benefits of AIMS

Implement AIMS controls

Create an AI policy

Define the process for reporting concerns about AI systems

Identify, document, and manage resources for AI systems

Ensure tooling and computing resources for AI systems are adequately documented

Conduct an AI system impact assessment exercise

Ensure that objectives are documented for the design and development of AI systems

Create a process for responsible design and development of AI systems

Ensure that AI system deployment, operation, and monitoring are documented and executed according to your AIMS

Define and implement data management processes for AI systems

Assess and document the quality of data for AI systems

Ensure that system documentation and information for users is provided and accessible

Document and follow the processes for the responsible use of AI systems

Clearly allocate and document responsibilities with third parties

Conduct internal audits

Regularly assess compliance with ISO 42001 and the effectiveness of AIMS

Management review

Review AIMS performance and compliance with top management

Address any non conformities and areas for improvement

Prepare for your external audit

Work with A-LIGN as your ISO 42001 certification body

Engage A-LIGN, a leading ISO certification body, to conduct your audit

Prepare documentation

Ensure all AIMS documentation is up to date and accessible

Pre-audit meeting

Prepare a list of questions and clarifications regarding the audit process

Initial sales process

Discuss the scope of the audit in detail to ensure full preparedness

Conduct a pre-certification audit (optional)

Consider a pre-certification audit to identify any remaining gaps

The ISO 42001 audit

Engage in the certification audit

Collaborate with A-LIGN auditors, providing necessary information and access

Designate a team member as the point of contact for auditors to streamline communication

Organize walkthroughs to discuss your AIMS processes and procedures, including facilities (if applicable)

Address audit findings

Plan for immediate, short-term, and long-term corrective actions based on the audit report

Celebrate the audit success with your team and publicly promote your certification

Continuous improvement

Establish a continuous improvement team to oversee progress post-certification

Continuously improve the AIMS, leveraging lessons learned and feedback

Integrate ISO 42001 compliance metrics into regular management reviews

Keys to success

Leverage Vanta s readiness capabilities and A-LIGN s expertise for an efficient and high-quality audit experience from  
readiness to report

Incorporate AIMS within the business strategy and daily operations

Apply continuous improvement to enhance AIMS over time

Avoid integrating new technologies during the initial AIMS implementation

Engage interested parties and maintain their support throughout

Highlight the completion of the audit to demonstrate trust with customers, partners, and other key stakeholders

Download this checklist for easy reference

Download now

Demonstrating secure AI practices with ISO 42001

The rapid adoption of AI has driven innovation and opportunities for growth — and with it, new risks for the companies that manage the data that power these technologies. These companies have not had a way to demonstrate trust to their customers and show that they are deploying AI securely and safely. Achieving ISO 42001 compliance helps to demonstrate this trust through a third-party verifiable way and opens the doors to time-savings, more deals, and expedited sales processes. The above checklist simplifies the process of becoming ISO 42001 compliant by leveraging the power of Vanta's continuous compliance software. Request a demo today to learn more about how Vanta can help you streamline the path to ISO 42001.

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Request a demo

Develop a roadmap for your ISMS implementation and ISO 27001 certification

Implement Plan, Do, Check, Act (PDCA) process to recognize challenges and identify gaps for remediation

Consider the costs of ISO 27001 certification relative to your organization’s size and number of employees.

Use project planning tools like project management software, Gantt charts, or Kanban boards.

Define the scope of work from planning to completion.

Determine the scope of your organization’s ISMS

Decide which business areas are covered by your ISMS and which ones are out of scope

Consider additional security controls for processes that are required to pass ISMS-protected information across the trust boundary.

Communicate the scope of your ISMS to stakeholders.

Establish an ISMS team and assign roles

Select engineers and technical staff with experience in information security to construct and implement the security controls needed for ISO 27001.

Build a governance team with management oversight.

Incorporate key members of top management (senior leadership and executive management) and assign responsibility for strategy and resource allocation.

If you have a large team, consider assigning a dedicated project manager to track progress and expedite implementation.

Align the team on the following:

The planning steps you’ve already taken

The scope of the ISMS

Which team members are responsible for which aspects of the project

Conduct an inventory of information assets

Consider all assets where information is stored, processed, and accessible

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Record information assets: data and people
Record physical assets: laptops, servers, and physical building locations
Record intangible assets: intellectual property, brand, and reputation

Assign to each asset a classification and owner responsible for ensuring the asset is appropriately inventoried, classified, protected, and handled

Meet with your team to discuss this inventory and ensure that everyone is aligned.

Perform a risk assessment

Establish and document a risk-management framework to ensure consistency

Identify scenarios in which information, systems, or services could be compromised

Determine likelihood or frequency with which these scenarios could occur

Evaluate potential impact of each scenario on confidentiality, integrity, or availability of information, systems, and services

Rank risk scenarios based on overall risk to the organization’s objectives

Develop a risk register

Record and manage your organization’s risks that you identified during your risk assessment.

Summarize each identified risk

Indicate the impact and likelihood of each risk.

Rank risk scenarios based on overall risk to the organization’s objectives.

Document a risk treatment plan

Design a response for each risk, known as a risk treatment.

Assign an owner to each identified risk and each risk mitigation activity.

Establish target timelines for completion of risk treatment activities.

Implement your risk mitigation treatment plan and track the progress of each task.

Complete the Statement of Applicability

Review the 93 controls listed in Annex A.

Select the controls that are relevant to the risks you identified in your risk assessment.

Complete the Statement of Applicability listing all Annex A controls, justifying inclusion or exclusion of each control in your ISMS implementation.

Implement ISMS policies, controls and continuously assess risk

Assign owners to each of the security controls to be implemented.

Figure out a way to track the progress and goals for each control.

Build a framework for establishing, implementing, maintaining, and continually improving the ISMS.

Include information or references to supporting documentation regarding:

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Information Security Objectives
Leadership and Commitment
Roles, Responsibilities, and Authorities
Approach to Assessing and Treating Risk
Control of Documented Information
Communication
Internal Audit
Management Review
Corrective Action and Continual Improvement
Policy Violations
All of the Annex A controls that you have selected

Establish employee training and awareness programs

Define expectations for personnel regarding their role in ISMS maintenance.

Train personnel on common threats facing your organization and how to respond.

Establish disciplinary or sanctions policies or processes for personnel found out of compliance with information security requirements.

Make security training part of the onboarding process for new employees.

Conduct regular training to ensure awareness of new policies and procedures.

Conduct regular management reviews

Plan reviews at least once per year. Consider a quarterly review cycle if your organization is large or if your infrastructure is changing frequently.

Ensure the ISMS and its objectives continue to be effective.

Verify that senior management stays informed.

Ensure risks or deficiencies can be promptly addressed.

Assemble ISO 27001 required documents

Review the ISO 27001 Required Documents and Records list.

Customize policy templates with organization-specific policies, process, and language.

Perform an ISO 27001 internal audit.

Examine each of the requirements from Annex A that you deemed applicable in your ISMS' Statement of Applicability and verify that you have each in place.

Assign in-house employees to conduct the internal audit, specifically employees who were not involved in the ISMS development and maintenance or hire an independent third party.

Share internal audit results, including nonconformities, with the ISMS team and senior management.

Address any issues your internal audit identified before proceeding with the external audit.

Verify compliance with the requirements from Annex A deemed applicable in your ISMS' Statement of Applicability.

Undergo external audit of ISMS to obtain ISO 27001 certification.

Select an independent ISO 27001 auditor.

Complete the Stage 1 Audit consisting of an extensive documentation review; obtain the auditor’s feedback regarding your readiness to move to the Stage 2 Audit.

Complete the Stage 2 Audit consisting of tests performed on the ISMS to ensure proper design, implementation, and ongoing functionality; evaluate fairness, suitability, and effective implementation and operation of controls.

Address any nonconformities.

Ensure that all requirements of the ISO 27001 standard are addressed.

Ensure your organization is following the processes that it has specified and documented.

Ensure your organization is upholding contractual requirements with third parties.

Address specific nonconformities identified by the ISO 27001 auditor.

Receive auditor’s formal validation following resolution of nonconformities.

Plan for subsequent ISO 27001 audits and surveillance audits.

Perform a full ISO 27001 audit once every three years

Prepare to perform surveillance audits in the second and third years of the Certification Cycle

Consider streamlining ISO 27001 certification with automation.

Explore tools for automating security and compliance

Transform manual data collection and observation processes into automated and continuous system monitoring

Identify and close any gaps in ISMS implementation in a timely manner

Learn more about achieving ISO 27001 certification with Vanta

Book an ISO 27001 demo with Vanta

Download this checklist for easy reference

Download now

Prioritizing your security and opening doors with ISO 27001 compliance

Information security is a vital priority for any business today from an ethical standpoint and from a business standpoint. Not only could a data breach jeopardize your revenue, but many of your future clients and partners may require an ISO 27001 report before they consider your organization. Achieving and maintaining your ISO 27001 compliance can open countless doors, and you can simplify the process with the help of the checklist above and Vanta’s compliance automation software.

‍

Request a demo today to learn more about how we can help you protect and grow your organization.

‍

Request a demo

Develop a roadmap for your ISMS implementation and ISO 27001 certification

Implement Plan, Do, Check, Act (PDCA) process to recognize challenges and identify gaps for remediation

Consider the costs of ISO 27001 certification relative to your organization’s size and number of employees.

Use project planning tools like project management software, Gantt charts, or Kanban boards.

Define the scope of work from planning to completion.

Determine the scope of your organization’s ISMS

Decide which business areas are covered by your ISMS and which ones are out of scope

Consider additional security controls for processes that are required to pass ISMS-protected information across the trust boundary.

Communicate the scope of your ISMS to stakeholders.

Establish an ISMS team and assign roles

Select engineers and technical staff with experience in information security to construct and implement the security controls needed for ISO 27001.

Build a governance team with management oversight.

Incorporate key members of top management (senior leadership and executive management) and assign responsibility for strategy and resource allocation.

If you have a large team, consider assigning a dedicated project manager to track progress and expedite implementation.

Align the team on the following:

The planning steps you’ve already taken

The scope of the ISMS

Which team members are responsible for which aspects of the project

Conduct an inventory of information assets

Consider all assets where information is stored, processed, and accessible

‍

Record information assets: data and people
Record physical assets: laptops, servers, and physical building locations
Record intangible assets: intellectual property, brand, and reputation

Assign to each asset a classification and owner responsible for ensuring the asset is appropriately inventoried, classified, protected, and handled

Meet with your team to discuss this inventory and ensure that everyone is aligned.

Perform a risk assessment

Establish and document a risk-management framework to ensure consistency

Identify scenarios in which information, systems, or services could be compromised

Determine likelihood or frequency with which these scenarios could occur

Evaluate potential impact of each scenario on confidentiality, integrity, or availability of information, systems, and services

Rank risk scenarios based on overall risk to the organization’s objectives

Develop a risk register

Record and manage your organization’s risks that you identified during your risk assessment.

Summarize each identified risk

Indicate the impact and likelihood of each risk.

Rank risk scenarios based on overall risk to the organization’s objectives.

Document a risk treatment plan

Design a response for each risk, known as a risk treatment.

Assign an owner to each identified risk and each risk mitigation activity.

Establish target timelines for completion of risk treatment activities.

Implement your risk mitigation treatment plan and track the progress of each task.

Complete the Statement of Applicability

Review the 93 controls listed in Annex A.

Select the controls that are relevant to the risks you identified in your risk assessment.

Complete the Statement of Applicability listing all Annex A controls, justifying inclusion or exclusion of each control in your ISMS implementation.

Implement ISMS policies, controls and continuously assess risk

Assign owners to each of the security controls to be implemented.

Figure out a way to track the progress and goals for each control.

Build a framework for establishing, implementing, maintaining, and continually improving the ISMS.

Include information or references to supporting documentation regarding:

‍

Information Security Objectives
Leadership and Commitment
Roles, Responsibilities, and Authorities
Approach to Assessing and Treating Risk
Control of Documented Information
Communication
Internal Audit
Management Review
Corrective Action and Continual Improvement
Policy Violations
All of the Annex A controls that you have selected

Establish employee training and awareness programs

Define expectations for personnel regarding their role in ISMS maintenance.

Train personnel on common threats facing your organization and how to respond.

Establish disciplinary or sanctions policies or processes for personnel found out of compliance with information security requirements.

Make security training part of the onboarding process for new employees.

Conduct regular training to ensure awareness of new policies and procedures.

Conduct regular management reviews

Plan reviews at least once per year. Consider a quarterly review cycle if your organization is large or if your infrastructure is changing frequently.

Ensure the ISMS and its objectives continue to be effective.

Verify that senior management stays informed.

Ensure risks or deficiencies can be promptly addressed.

Assemble ISO 27001 required documents

Review the ISO 27001 Required Documents and Records list.

Customize policy templates with organization-specific policies, process, and language.

Perform an ISO 27001 internal audit.

Examine each of the requirements from Annex A that you deemed applicable in your ISMS' Statement of Applicability and verify that you have each in place.

Assign in-house employees to conduct the internal audit, specifically employees who were not involved in the ISMS development and maintenance or hire an independent third party.

Share internal audit results, including nonconformities, with the ISMS team and senior management.

Address any issues your internal audit identified before proceeding with the external audit.

Verify compliance with the requirements from Annex A deemed applicable in your ISMS' Statement of Applicability.

Undergo external audit of ISMS to obtain ISO 27001 certification.

Select an independent ISO 27001 auditor.

Complete the Stage 1 Audit consisting of an extensive documentation review; obtain the auditor’s feedback regarding your readiness to move to the Stage 2 Audit.

Address any nonconformities.

Ensure that all requirements of the ISO 27001 standard are addressed.

Ensure your organization is following the processes that it has specified and documented.

Ensure your organization is upholding contractual requirements with third parties.

Address specific nonconformities identified by the ISO 27001 auditor.

Receive auditor’s formal validation following resolution of nonconformities.

Plan for subsequent ISO 27001 audits and surveillance audits.

Perform a full ISO 27001 audit once every three years

Prepare to perform surveillance audits in the second and third years of the Certification Cycle

Consider streamlining ISO 27001 certification with automation.

Explore tools for automating security and compliance

Transform manual data collection and observation processes into automated and continuous system monitoring

Identify and close any gaps in ISMS implementation in a timely manner

Learn more about achieving ISO 27001 certification with Vanta

Book an ISO 27001 demo with Vanta

Download this checklist for easy reference

Download Now

Plan strategically when scheduling and timing your audit

Sometimes, the biggest roadblock to scheduling an audit is knowing where to start. Here are a few tips for taking your first big step in the audit process.

Check into your chosen firm’s availability. Small auditing firms tend to have more limited time and need more advance notice, while larger firms have more resources and, therefore, more availability. However, larger firms can cost more to hire.

Give yourself enough time before the audit. In many cases, audits don’t just check to see if you’ve done an activity once; they look for evidence of continuous controls. Plan to collect consistent evidence over at least three months to demonstrate this.

Choose a dedicated team or team member who will be available throughout the audit. Your auditor will need a go-to person to provide all the proper information and be available for any follow-up questions. Check calendars of others stakeholders involved with the audit controls to ensure they’ll be present when you schedule your audit on-site or live sessions.

Be aware of commitments and deadlines. You will likely sign a statement of work (SOW) when you schedule an audit. Your team is responsible for meeting all the deadlines outlined in this SOW. The auditor will need the correct information from your team in a timely manner to do their job.

Pro tip: Make sure your team understands the difference between the “audit window” or “review period” and the length of the audit itself. The “audit window” is the timeframe the auditors will use to gauge if you’ve been consistent with your controls. Typically, they require three months or more. This time period is different from the 1-4 weeks that the auditor will be inside your organization, conducting the audit itself.

Prepare your team in advance

Once you’ve scheduled your audit, it’s time to work with your team and assign tasks to the appropriate owners. An audit requires participation from several teams, from engineering to IT to sales. Here are a few ways to prepare these teams for audit-related activities:

Know which framework(s) you’re working towards and communicate the requirements to your team. If you’re going to work towards multiple frameworks simultaneously, identify overlaps so you don’t duplicate work. A tool like Vanta helps break down requirements and map them to action items.

Understand which evidence each team needs to provide. Next, communicate requirements and deadlines to each department. It’s a good idea to use a central hub that can show all preparation activities and who is responsible for each one.

Inform your team why this is an important activity so they understand that the time and commitment are worthwhile for them. Connect it to outcomes and KPIs that matter to their teams whenever possible. Audits ultimately prove your company’s commitment to security and trust, and meeting a framework can be the difference between growing your business and missing out on opportunities.

Communicate to your team that the goal is progress, not perfection. If it’s your first time getting audited against a particular framework, you probably won’t get a perfect score, and that’s okay! Instead, make it your goal to set a baseline for meeting the framework, then find ways to improve your controls over time.

Pro tip: As you and your team prepare for the audit, remember to do your due diligence before the auditor even arrives. Get to know exactly how your controls align with the framework and be realistic about which shortcomings you expect the auditor will likely find. That way, you won’t be surprised by the audit’s findings.

Manage your evidence

As your team prepares for an audit, collecting evidence of your activities is just as important as completing the activities themselves. For example, you will likely need to draft formal security policies and protocols (for example, this is one of the requirements for SOC 2). But you can’t just say, “We have the required security policies.” You’ll need to provide your auditor with a hard copy of your policies. And this is just one of the many controls they will require you to prove with documentation.

Managing evidence gets complicated quickly, considering how many documents your auditor will require. So, it’s your job to make sure that evidence is organized and ready as soon as the auditor asks for it. Here are a few tips for compiling the proper evidence to be fully prepared when the auditor arrives:

Ensure your evidence shows consistency —not just point-in-time or static documentation. You should be able to prove that you’ve maintained the proper controls throughout your audit window. A tool like Vanta that supports continuous controls monitoring can help with this.

Compile and store your documentation in a way that simplifies sharing the relevant evidence with the auditor. You want to spend as little time as possible chasing down specific documents or screenshots during the audit. Getting organized beforehand means far less stress for your team when the auditor begins their assessment. Vanta can help you stay on top of your documentation by storing all documents in a centralized location and automatically updating data with real-time changes.

Get to know your evidence inside and out. You shouldn’t be surprised by anything that your auditor finds. It helps to use a governance, risk, and compliance (GRC) automation tool to parse through the documentation and summarize findings. This way, you have a consolidated view of evidence rather than a bunch of disparate documents and files that are hard to consume at once.

Be transparent and upfront with your evidence. Don’t try to shape a specific story or alter the truth by showing more or less documents to an auditor. Honesty is always the best policy in these cases, especially considering the potential consequences of lying in an audit. Altering the truth can significantly impact the integrity of your company, or even prevent you from requesting audits in the future.

Pro tip: Be transparent without embellishing the truth when the auditor arrives. Let your evidence speak for itself. You might think this goes without saying, but the temptation to overshare or embellish can get the best of anyone when the audit actually begins.

Work closely with your auditor

Many organizations enter the auditing process with concerns about their relationship with the auditor. Fortunately, in most cases, the process will be less like a test proctored by an intimidating professor and more of a back-and-forth conversation with an industry expert who knows best how to get you to your goals.

Here’s some advice for working with your auditor and making it a better experience for both of you:

Look for specialization. Find an auditor specializing in the framework(s) you’re working toward. You can start by asking for recommendations within your industry—Vanta’s network of trusted auditors is a great place to start.

Help your auditor understand your business. You will need to guide them through the ins and outs of your organization, including where your controls reside and which insights they provide to your business. They won't know where to start assessing your controls if they don’t understand your organization or GRC processes and tools.

Treat the audit like a conversation. In most cases, your auditor will be inside your organization for a few weeks to months, and during that time, it should become a back-and-forth working relationship. The auditor will likely ask you for specific evidence over time, and you will work with them directly to provide each piece of information they need, and so on.

Maintain the relationship with your auditor afterward. They can serve as a helpful resource as you build out your GRC initiatives and continuously maintain and improve compliance over time. While auditors can’t give direct advice on how to do something, most are more than willing to help wherever they can. For example, if you plan to change your tech stack, employee policies, etc., consider asking your auditor how these changes will impact future audits before committing to the change.

Pro tip: Keep in mind that it’s common practice to switch your auditor every few years to avoid bias. But once you’ve found a firm and auditor you like, you can always ask them for recommendations and referrals to find your next auditor.

Take your audit results to the next level

An audit isn’t just a one-and-done activity—it’s the beginning of a journey toward a stronger security posture over time. To get the most out of your audit findings, prepare your team to work on the following initiatives after the audit is done:

Share your new compliance status with the right audiences. Many businesses rely use a public-facing site (like Vanta Trust Center) to display their real-time GRC efforts. Your prospective customers can then use this data to expedite security questionnaires and provide proof points to key decision-makers.

Track KPIs that show your response to the gaps that your auditor finds. The specifics of these KPIs will depend on your particular business, priorities, etc. In general, they should center around risk reduction and remediation efforts. For instance, if you have any findings, opportunities for improvement (OFI), or nonconformities listed in your report, track the response to these insights over time. How are you changing processes? What new tools have you implemented?

Consider conducting a readiness assessment between formal external audits. Businesses will typically either hire a third party or pick a team member who isn’t involved in any GRC activities to perform this type of audit. The best way to incorporate readiness assessments into your processes without causing business disruption is to use continuous monitoring to get an instant snapshot of all existing controls.

Treat your audit like a jumping-off point for security initiatives. Meeting a particular framework doesn’t necessarily equate to bulletproof security. For example, a compliance framework often doesn’t account for emerging threats. Still, consistently meeting the controls listed in a framework is a great starting point for establishing a strong security culture throughout your organization.

Foster a strong security culture. As you respond to your audit findings and implement stronger GRC controls, your team members need to understand why specific controls exist and how to play a role in meeting them. Ultimately, this is all about fostering a strong security and risk management culture throughout your organization. Consider rolling out security training and tracking KPIs such as phishing drill click-through rates and training completion rates. This will help demonstrate progress for future audits as well as improving your organization’s security posture.

Anatomy of an audit report

Knowing what to expect when you finally get that audit report can help you set expectations for internal and external stakeholders ahead of time. Here’s what the typical audit report should contain:

Executive summary: A high-level recap of the report’s purpose, the standard/framework in question, etc.
Scope: An in-depth description of the scope that the audit covered. For example, was it a corporate-wide evaluation, a test on a specific application, or something else?
Testing information: A detailed list of all tests the auditor ran, such as policy reviews, artifact evaluations, and on-site observations.
Testing results: A report on the results of these tests, including any exceptions.
Management responses: The management team’s explanations as to why an exception exists and how they will respond to it in the future.
Conclusion: The auditor’s opinion on the assessment. Keep in mind that this area of the report will rank the company by maturity, not as a pass or fail.

While compliance audits can feel overwhelming because of the time and resources that they require, they offer your team the unique opportunity to start a journey toward stronger security and deeper customer trust. Plus, tasks like scheduling, managing evidence, and working with your auditor don’t have to feel so daunting if you go into your next audit with the right expectations and preparation.

Confirm which CMMC level your business needs

The first step of the CMMC program and becoming CMMC certified is confirming what CMMC level you’re on. Here are a few ways you can confirm what level your business needs.

Determine the type of data you handle. If you handle FCI, you’ll likely fall under level 1, whereas if you handle CUI, you will be under level 2 or 3. If you handle a variety of FCI and CUI information, you must be certified at the level encompassing all the information you handle.

Check your contract. If you currently have a contract, reach out to your contracting officer. They can help determine your level and the requirements to remain compliant. As you bid on future contracts, the DoD will specify the required CMMC level and assessment type for eligibility in the solicitation and resulting contract.

Perform a self-assessment. If you don’t currently have a contract, but hope to in the future, the best thing you can do is perform a self-assessment of your systems. This ensures you meet the necessary security requirements and have implemented proper controls to protect sensitive information. It will also give you an idea of what level you’re at.

Establish your FCI and CUI boundaries

Once you confirm what level of certification you need, your next step is to figure out what systems, processes, and data—referred to as assets—fall under CMMC requirements. The DoD refers to this process as establishing your boundaries for FCI and CUI.

Review boundaries and assessment scope guidelines for your CMMC level. Each level has set boundaries and assets based on the information that’s handled. Once you know your level, you can review general guidelines for assessment scope.

Identify in-scope assets. For each level, there will be set assets that are considered in scope. Depending on the certification you’re seeking, you’ll need to identify all assets that process, store, or transmit FCI or CUI data. This includes all people, technology, facilities, and external service providers. For levels 2 and 3, this also includes specialized assets, security protection assets, and contractor risk managed assets.

Document in-scope assets. Once you’ve identified all assets in scope, you’ll need to document them. Documentation includes creating an asset inventory and providing a network diagram, which will be a part of your official assessment.

Pro tip: At each level, any asset that isn’t in scope is considered out-of-scope, meaning it doesn’t need to be documented during an assessment. For more information on what assets are considered in and out of scope, the DoD has scoping guidelines for each level.

Perform a gap assessment

Once you’ve established your CUI and FCI boundaries and your organization’s current status, you’ll want to conduct a gap assessment, also known as a CMMC gap analysis, to identify areas where your organization is falling short. A good gap assessment helps reduce the stress of prepping for CMMC certification since it’ll show you any areas or processes you need to focus on to pass level assessments and get certified. To perform a gap assessment, you’ll want to:

Identify and document existing controls. Map your current security controls to the objectives outlined in the CMMC framework. This includes documenting asset treatment in a system security plan (SSP).

Identify and document controls not yet satisfied. Identify and review controls that you haven’t yet satisfied. You’ll want to pay close attention to this step as these controls need to be addressed and satisfied to pass certification during an official assessment.

Pro tip: As you complete your gap assessment, you’ll likely need to collaborate with stakeholders across the business to ensure you have up-to-date information. Improper documentation or oversight of required controls could result in your organization not meeting CMMC certification requirements.

Create and execute a plan of action and milestones

As you work through the steps of planning and preparing for CMMC certification, you’ll also need a Plan of Action and Milestones (POA&M).

Create a POA&M. A POA&M allows companies to create a roadmap for improvement with details on what to prioritize, steps for action, who’s responsible for them, resources needed, and deadlines. Any company seeking CMMC certification can complete a POA&M after their gap assessment.

Execute your POA&M. The actions and steps outlined in your POA&M should make the process easier. But, take it step by step. Attempting to remediate every action at once makes it hard to track progress. It could also result in accidentally overlooking important steps, security gaps, or unresolved issues, which can impact your official assessment.

Regularly monitor progress and gather evidence. As you begin implementing new controls, document and monitor progress. This includes validating control design and regularly reviewing your progress against milestones. You’ll also want to gather evidence surrounding them. Evidence should include steps you’ve taken to implement controls and any results from it. If controls result in new policies and procedures, document those as well.

Pro tip: Along with completing a POA&M, you should document your Supplier Performance Risk System (SPRS) score. An SPRS score ranges from -230 to +110 and helps the DoD understand how well a contractor is protecting sensitive data and government information. Determining your SPRS score can ensure you focus on the right areas when working towards CMMC certification.

Conduct assessment

If you’ve completed steps one through six, conducting the assessment should go smoothly. Ideally, you’ve addressed all security gaps and areas of improvement in your POA&M, so there shouldn’t be any surprises during the official assessment. Like most of the CMMC certification process, the type of assessment you conduct will depend on your level.

Level 1

Conduct a self-assessment against level 1 security requirements. Level 1 only requires a self-assessment.

Gather and prepare evidence. A self-assessment requires the submission of documents and evidence, such as policy and process documents, training materials, and planning documents. It also requires interviews with employees and testing to ensure processes are followed.

Ensure all level 1 security requirements are met or marked as “not applicable.” To achieve level 1, all security requirements must be met or not applicable, with results entered into the SPRS.

Level 2

Determine which assessment is required. Level 2 has two types of assessments, a self-assessment or a certification assessment. Self-assessments for level 2 are the same as level 1. For a certification assessment, a C3PAO must complete it.

Gather and prepare evidence. The documents, interviews, and testing laid out in level 1 are required for level 2 certification.

Determine if you’re eligible for a conditional or final level 2. A level 2 assessment can result in a conditional or final level 2. A conditional level 2 will require a POA&M. To achieve level 2, all security requirements must be met or not applicable.

Update your POA&M for final certification if you receive a conditional level 2. To achieve a final level 2, you must complete or close out your POA&M within 180 days.

Level 3

Achieve final level 2 certification with a C3PAO. Level 3 requires two assessments. Both must be completed to achieve level 3 certification. The first assessment is achieving final level 2 with a C3PAO.

Complete an assessment with the Defense Contract Management Agency (DCMA) DIBCAC. This assessment is based on level 3 requirements. The DCMA DIBCAC assessment can result in a conditional or final certification.

Update your POA&M for final certification if you receive a conditional level 3. To achieve final level 3, you must complete or close out your POA&M in 180 days.

Maintain certification

After putting in the work to officially become CMMC certified, you’ll need to maintain your certification. Due to the quickly evolving nature of cybersecurity, the DoD requires CMMC-certified organizations to review their controls and affirm compliance annually. Depending on your level, assessments take place annually or every three years.

Level 1

Complete a self-assessment annually. Similar to initial certification, you must complete the self-assessment and enter it into the SPRS every year.

Complete an annual affirmation. The annual affirmation verifies compliance with the 15 basic safeguarding requirements in FAR clause 52.204-21, Basic Safeguarding of Covered Contractor Information Systems.

Level 2

Complete an annual affirmation. For both self and C3PAO certifications, an annual affirmation verifying compliance with the 110 security requirements in NIST SP 800-171 Revision 2, Protecting Controlled Unclassified Information in Nonfederal Systems and Organizations needs to be completed and entered into the SPRS.

Complete a self- or C3PAO assessment every three years. Results of a self assessment must be entered into the SPRS. C3PAO results must be entered into the CMMC Enterprise Mission Assurance Support Service (eMASS).

Level 3

Complete an affirmation annually. An annual affirmation must be completed to verify compliance with the 24 identified requirements from NIST SP 800-172 and entered into the SPRS.

Complete a DIBCAC assessment every three years. Results of a DIBCAC assessment must be entered into CMMC eMASS.

How Vanta makes CMMC certification easier

While CMMC certification can feel overwhelming, having tools to help you prepare for and maintain certification is key.

‍Vanta makes it easier to meet CMMC requirements across all three levels. Through a centralized platform, Vanta can guide you through the step-by-step process of obtaining and monitoring your CMMC implementation.

Additionally, Vanta’s extended partner network offers hands-on support to ensure you can successfully implement CMMC and conduct assessments to renew contracts and win new business.

‍A note from Vanta: Vanta is not a law firm, and this article does not constitute or contain legal advice or create an attorney-client relationship. When determining your obligations and compliance with respect to relevant laws and regulations, you should consult a licensed attorney.

Pre-work for your Cyber Essentials certification

Evaluate your need for Cyber Essentials. You can assess whether you need a Cyber Essentials certification based on the following criteria:

Do you collect or process sensitive or personal data from UK residents?

Have you ever been asked about Cyber Essentials by clients or prospects?

Do your competitors have Cyber Essentials certification?

Are you working with companies that provide public services in the UK?

Choose the right Cyber Essentials certification. Although both versions of the Cyber Essentials frameworks have the same requirements, Cyber Essentials Plus involves a third-party audit and technical testing. As a result, Cyber Essentials Plus provides an extra layer of security validation beyond the self-assessment in the standard Cyber Essentials certification.

Do you need Cyber Essentials or Cyber Essentials Plus?

Here are some helpful considerations for deciding whether to pursue the Cyber Essentials certification or Cyber Essentials Plus:

Determine your budget. Cyber Essentials Plus is more expensive than Cyber Essentials because of the external audit and higher security assurance. Pricing for Cyber Essentials ranges from £320 to £600 (plus VAT). Cyber Essentials Plus does not have a fixed pricing structure, but estimates start at £1,499 (plus VAT) and increase based on your organisation’s size and complexity. Learn more about Cyber Essentials costs.

Assess your time and team resources. Cyber Essentials Plus requires more time and bandwidth and takes longer to complete, especially for smaller companies (or security teams) with limited internal resources.

Understand your stakeholders’ concerns. The Cyber Essentials Plus third-party audit requirement enables you to demonstrate your commitment to enterprise-wide data security and assure stakeholders who may have security concerns.

Define customer requirements. Cyber Essentials Plus is required to win UK government contracts. It may also be required to conduct business with certain companies in the UK, such as those looking to prevent potential supply chain-related cyber threats from impacting their operations.

Evaluate your infrastructure size and complexity. Larger, more complex entities whose interconnected assets and operations are at high risk of being disrupted by cyber threats may benefit from Cyber Essentials Plus. Its rigour ensures reliable safeguards protect this infrastructure.

Estimate the volume and sensitivity of stored data. Companies that handle vast amounts of sensitive data (such as PHI in healthcare) may gain higher assurance with Cyber Essentials Plus.

Prepare for your Cyber Essentials certification

First, identify your Cyber Essentials requirements.

Obtaining a Cyber Essentials certification requires you to implement controls across five categories:

Firewalls: All firewalls deployed to system boundaries, endpoints, servers, cloud services, and other critical infrastructure entry points should have the correct security configurations, access controls, and security rules.

Secure configurations: All configurations applied to endpoints and networked services should reduce exploitable vulnerabilities while enabling the completion of business-critical services.

User access controls: Access to all user accounts should require authorisation, and only the people who need access to specific endpoints, services, or applications to complete business tasks should have access. Consider using time-bound or just-in-time access and implementing the principle of least privilege (PoLP) to tighten user access controls.

Malware protection: Administrators should establish the appropriate security mechanisms to prevent malware intrusion via known and unknown sources. They should also educate employees and third parties on the risks of malware and ransomware and how to avoid social engineering scams.

Security updates: All devices and software at risk for security flaws should be updated regularly to ensure their configurations are secure and in alignment with recommended industry/manufacturer security standards.

Gap analysis and remediation

Conduct a gap analysis. Evaluate IT infrastructure for gaps in the above control categories.

Document gaps and develop a remediation plan. Documenting the gaps identified and proposing actionable steps to rectify them is critical.

Address gaps that could lead to security vulnerabilities. Following a gap analysis, you may need to remediate sources of exploitable vulnerabilities.

Examples of remediation steps include:

Changing default administrative passwords into stronger, unique ones

Deactivating unnecessary user accounts that are not currently in use

Scheduling automatic system and network security updates

Implementing multi-factor authentication for all user accounts

Installing anti-malware software on all devices

Test all applicable controls. It’s critical to monitor devices and networks to verify the effectiveness of implemented controls in preparation for assessment. Test your controls and make sure they are functioning properly.

Document findings from system monitoring. It’s also helpful to record all the information from monitoring in an organised, shareable report format to keep track of it. Doing so manually is a challenge for any organisation, which is where automation solutions, like Vanta, help reduce these burdens and enable organisations to scale their security monitoring capabilities as they grow.

Complete the self-assessment (for Cyber Essentials)

After you’ve identified the Cyber Essentials requirements that apply to your organisation and remediated any security gaps, the next step towards becoming Cyber Essentials certified is to complete the self-assessment, which is required even when you’re aiming for the Cyber Essentials Plus certification. Here are the steps our team of compliance experts recommend taking:

Prepare for the Cyber Essentials self-assessment. Train all parties involved in the certification process so they are on the same page regarding Cyber Essentials documentation. Building and maintaining a security awareness culture is crucial for your organisation to fully comply with Cyber Essential security guidelines during its day-to-day operations beyond preparing for the Cyber Essentials self-assessment (or audit, if you choose to pursue Cyber Essentials Plus).

Conduct the self-assessment questionnaire. (SAQ). When ready, you can complete an online SAQ and have a senior team member validate it to get the Cyber Essentials certificate. It’s essential to be accurate and truthful when answering questions to ensure alignment with the necessary standards for obtaining the certificate.

Use online readiness tools to prepare for the test. Tools like the IASME Cyber Essentials Readiness Tool provide free questions to help you assess the posture of your company’s controls and their impact on your business operations. These questions are designed to inform you about your current readiness so you can develop a tailored action plan for the Cyber Essentials audit.

Decide whether you need the Cyber Essentials Plus audit. You can choose to obtain the Cyber Essentials Plus certification immediately after the Cyber Essentials self-assessment or in the following months. While you must complete just the self-assessment to obtain the Cyber Essentials certification, you’ll also need to complete and pass an external audit to receive the Cyber Essentials Plus certification.

Complete the external audit for Cyber Essentials Plus

Prepare for the Cyber Essentials Plus audit. If you want to obtain a Cyber Essentials Plus certification, you should ensure your SAQ was certified within three months of applying for the Cyber Essentials Plus.

Identify an independent assessor: Work with a highly-trained assessor to verify that all currently implemented controls align with the Cyber Essentials Plus requirements.

Review audit findings and implement remedial actions (if any): Address any gaps identified during the independent assessment within a set period.

Obtain Cyber Essentials Plus certification: A successful Cyber Essentials Plus certification provides a certificate valid for 12 months following the assessment pass date. Then, you can become designated as a CE-certified company, opening new business opportunities in the private sector or with the UK government.

Maintain ongoing Cyber Essentials or Cyber Essentials Plus certification

Monitor your IT infrastructure regularly. Organisations need continuous internal assessments to verify adherence to the Cyber Essentials security guidelines. As systems and networks age, they are exposed to more vulnerabilities. So, you need to review your existing security configurations and ensure they still match the rigorous standards of the Cyber Essentials or Cyber Essentials Plus program.

Renew your Cyber Essentials certification.The Cyber Essentials and Cyber Essentials Plus certifications expire after 12 months and must be renewed yearly. Renewing these certifications helps you maintain your designation as a Cyber Essentials-certified company and provides assurance to current and future stakeholders.

Implement zero-trust principles. As the cyber risk environment becomes more complex, consider implementing zero trust across systems and networks to keep your data safe. New technologies are constantly emerging, meaning cybercriminals are also looking for the easiest gaps to exploit to access sensitive data for malicious gain.

Streamline Cyber Essentials certification with Vanta

A strong security posture will enable organisations to build customer trust and expand business to or within the UK. However, it’s cumbersome to manually keep track of all the processes necessary to obtain Cyber Essentials or Cyber Essentials Plus certification.

Fortunately, Vanta automates up to 70% of the UK Cyber Essentials process (including evidence collection), dramatically simplifying the compliance process. This enables teams to focus on strengthening their security programs without redundancy.

Plus, with Vanta, you don’t need to duplicate your compliance efforts across multiple frameworks. UK Cyber Essentials has significant overlap with frameworks like ISO 27001. If you’re already compliant with ISO 27001, you don’t need to reinvent the wheel; Vanta automatically cross-references other frameworks and surfaces any overlapping controls that you already have in place.

Vanta’s trust management expertise can help startups and early-stage companies in the UK build and optimise their security programs to obtain the Cyber Essentials certification. Thousands of global customers rely on Vanta’s real-time, transparent trust management platform to demonstrate their focus on security and privacy to stakeholders.

Learn more about how Vanta automates Cyber Essentials compliance.

Pre-work for your HITRUST certification

Align your goals: Ensure that pursuing a HITRUST certification aligns with your business goals and programs

Find internal stakeholders: Identify key stakeholders within your organization, such as champions who can drive internal buy-in, and a project owner to drive the certification process

Educate leadership: Educate your team, executives, and the board on the HITRUST process, implied changes, and the added value to your organization of attaining certification

Work for your HITRUST certification

Understand the HITRUST CSF: Familiarize yourself with the control requirements of the HITRUST CSF

Identify compliance needs: Determine your organization's specific compliance requirements

Select appropriate HITRUST assessment type: Choose between e1, i1, or r2 assessment, according to needs of your business and your risk profile

Use Vanta to streamline the assessment: Use Vanta to identify and remediate gaps in your compliance program

Find an external assessor: Work with Vanta to select a HITRUST Validated Assessor—A-LIGN, Prescient Assurance, or Insight Assurance—to guide you through and to conduct your Readiness assessment

Purchase MyCSF subscription: Work with Vanta to initiate the procurement process for your Validated Assessor, MyCSF subscription, and report credit (if required)

Attend the HITRUST course: Gain insights and guidance through HITRUST’s New Customer Orientation

Readiness assessment

Define assessment scope: Identify the areas and systems to be included in the assessment and communicate the intended timeline of certification to your chosen Validated Assessor

Perform initial assessment: Work with your external assessor to identify gaps using Vanta

Initiate inheritance plans: Create plans for internal or external inheritance of controls

Make inheritance requests: Submit inheritance requests via the MyCSF platform

Secure QA date: Schedule a date for post-submission HITRUST QA review

Remediation

Resolve gaps: Use Vanta to identify and remediate any evidence gaps identified during the readiness assessment

The Validated Assessment

Validated assessment

Provide evidence: Collect and submit necessary evidence to your external assessor

Finalize inheritance: Confirm all inheritance plans

Support External Assessor: Be available for any additional validation requests

Address issues: Resolve any issues noted during the pre-submission QA

Submission and Review

Submit assessment: Submit the relevant evidence to your chosen Validated Assessor to input into MyCSF for HITRUST to review

Support QA process: Be available to assist your external assessor with any QA queries

Certification

Review certification report: Check and approve the draft certification report

Ensuring compliance over time and beyond

Ongoing Monitoring

Remediate gaps: Use Vanta to continue to monitor your state of compliance and continue to close gaps

Plan for the next assessment

Future planning: Prepare for your next HITRUST assessment to maintain compliance, manage risks, and enhance security —
leveraging inheritance where appropriate

Advancing your assessment: Consider expanding your security posture by exploring the different levels within the HITRUSTecosystem — from e1 to i1 and i1 to r2

Leverage the business benefits of HITRUST certification, including

Commercial compliance: Satisfy customer, contractual requirements or preferences for HITRUST certification

Market access: Gain access to new or additional markets that require or prefer HITRUST certification

Market differentiator: Demonstrate the highest level of security posture as a vendor or partner

Risk mitigation: Adopt proven, repeatable, and measurable methods ensure significant risk reduction in certified environments
(only 0.64% of experienced breaches over two years)

Value creation: Improve potential valuation with investors and shareholders

Liability reduction: Protect yourself and your organization by using a prescriptive, complete, and proven framework to plan,  
build, execute, and validate your cybersecurity program instead of building your own

Regulatory compliance: Reuse and restate HITRUST validated controls using HIPAA, SOC 2, ISO 27001, GDRP, and others to  reduce compliance efforts

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Determine which annual audits and assessments are required for your company

Perform a readiness assessment and evaluate your security against HIPAA requirements

Review the U.S. Dept of Health and Human Services Office for Civil Rights Audit Protocol

Conduct required HIPAA compliance audits and assessments

Perform and document ongoing technical and non-technical evaluations, internally or in partnership with a third-party security and compliance team like Vanta

Document your plans and put them into action

Document every step of building, implementing, and assessing your compliance program

Vanta’s automated compliance reporting can streamline planning and documentation

Appoint a security and compliance point person in your company

Designate an employee as your HIPAA Compliance Officer

Schedule annual HIPAA training for all employees

Distribute HIPAA policies and procedures and ensure staff read and attest to their review

Document employee trainings and other compliance activities

Thoroughly document employee training processes, activities, and attestations

Establish and communicate clear breach report processes
to all employees

Ensure that staff understand what constitutes a HIPAA breach, and how to report a breach

Implement systems to track security incidents, and to document and report all breaches

Institute an annual review process

Annually assess compliance activities against theHIPAA Rules and updates to HIPAA

Continuously assess and manage risk

Build a year-round risk management program and integrate continuous monitoring

Understand the ins and outs of HIPAA compliance— and the costs of noncompliance

Download this checklist for easy reference

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Access Review Stage	Content / Functionality
Across all stages	Easily create and save a new access review at a point in time View detailed audit evidence of historical access reviews
Setup access review procedures	Define a global access review procedure that stakeholders can follow, ensuring consistency and mitigation of human error in reviews Set your access review frequency (monthly, quarterly, etc.) and working period/deadlines
Consolidate account access data from systems	Integrate systems using dozens of pre-built integrations, or “connectors”. System account and HRIS data is pulled into Vanta. Upcoming integrations include Zoom and Intercom (account access), and Personio (HRIS) Upload access files from non-integrated systems View and select systems in-scope for the review
Review, approve, and deny user access	Select the appropriate systems reviewer and due date Get automatic notifications and reminders to systems reviewer of deadlines Automatic flagging of “risky” employee accounts that have been terminated or switched departments Intuitive interface to see all accounts with access, account accept/deny buttons, and notes section Track progress of individual systems access reviews and see accounts that need to be removed or have access modified Bulk sort, filter, and alter accounts based on account roles and employee title
Assign remediation tasks to system owners	Built-in remediation workflow for reviewers to request access changes and for admin to view and manage requests Optional task tracker integration to create tickets for any access changes and provide visibility to the status of tickets and remediation
Verify changes to access	Focused view of accounts flagged for access changes for easy tracking and management Automated evidence of remediation completion displayed for integrated systems Manual evidence of remediation can be uploaded for non-integrated systems
Report and re-evaluate results	Auditor can log into Vanta to see history of all completed access reviews Internals can see status of reviews in progress and also historical review detail