HIPAA Security Rule Risk Assessment
1. Scope of Analysis
The risk analysis required by 45 C.F.R. § 164.308(a)(1)(ii)(A) was conducted across all production information systems of the Company that may create, receive, maintain, or transmit Electronic Protected Health Information ("ePHI") on behalf of Covered Entity customers. In-scope systems include the Company's AWS production accounts (account 884135110852 commercial; the federal-track GovCloud account is reviewed separately), the customer-facing portals at retail.jilsovereign.com and admin.jilsovereign.com, the AVA™ Pro and AVA™ Pro+ analytical pipeline, the Bedrock and SageMaker inference paths, and all supporting databases, queues, and audit ledgers.
2. Reasonably Anticipated Threats
The Company identified and evaluated the following threat categories:
- External adversary: credential-stuffing, exploitation of unpatched vulnerabilities, supply-chain compromise of dependencies, ransomware against application data.
- Insider risk: malicious or accidental misuse of authorized access by personnel or subcontractors.
- Subprocessor compromise: compromise of an authorized subprocessor (principally AWS) that could expose ePHI.
- Operational error: misconfiguration leading to public exposure of an otherwise-protected resource; data loss from inadequate backup.
- Natural and environmental: regional outage of cloud infrastructure; environmental disaster affecting data centers.
- Legal and regulatory: lawful demand for ePHI without sufficient process; conflicting legal obligations across jurisdictions.
3. Vulnerabilities Identified and Treatment
The Company maintains an active risk register in which each identified vulnerability is rated for likelihood and impact, assigned an owner, and tracked through treatment. Treatment categories used:
- Mitigate - implement compensating controls.
- Transfer - shift risk to insurance or to a contracted party.
- Accept - document residual risk and management decision to accept.
- Avoid - eliminate the activity giving rise to the risk.
The current register contains residual risks rated High, Medium, or Low. No residual risks rated Critical are open at the date of this Summary.
| Domain | Open Risks | Top Treatment Action |
|---|---|---|
| Encryption and Key Management | 0 High, 1 Medium | CloudHSM rotation procedure documented; quarterly rotation rehearsal scheduled. |
| Identity and Access | 0 High, 0 Medium | WebAuthn enforced for all privileged paths; just-in-time elevation required for operator-to-PHI access. |
| Audit Logging | 0 High, 0 Medium | S3 Object Lock Compliance mode in place; CourtChain™ anchoring in place; quarterly integrity verification. |
| Network | 0 High, 1 Medium | Private subnet posture in place; pending hardening: cross-region VPC peering with stricter route table. |
| Vulnerability Management | 0 High, 2 Medium | Snyk in CI; AWS Inspector weekly; pending: SBOM generation per release. |
| Subprocessor Risk | 0 High, 0 Medium | AWS BAA executed; annual AWS audit-report review. |
| Continuity | 0 High, 1 Medium | Multi-region failover tested; pending: cold-region disaster-recovery rehearsal. |
| Personnel | 0 High, 1 Medium | Security training program codified; pending: role-specific incident-response training for engineering on-call. |
4. Required Implementation Specifications - Status
The Security Rule administrative, physical, and technical safeguards have been mapped to the Company's controls. All Required Implementation Specifications are met. All Addressable Implementation Specifications are either met as written or addressed by an equivalent compensating control documented in the internal control mapping.
5. Reassessment Cadence
This risk analysis is performed at least annually, and additionally upon any of the following triggers:
- material change to information systems handling ePHI;
- addition or removal of a subprocessor with access to ePHI;
- any reportable security incident or near-miss;
- material change to applicable law or regulatory guidance.
6. Conclusion
Based on the foregoing, the Company has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of ePHI as required by the HIPAA Security Rule. Residual risks are documented, owned, and tracked through the Company's risk management program.