Information Backup

The HITRUST information backup requirement expects you to run policy-driven backups of covered information and software, protect those backups with access controls and encryption, and regularly test restoration so you can prove recovery works. To operationalize it fast, define schedules and retention, automate backups, run documented restore tests, and retain evidence that each step happened. ¹

Key takeaways:

• Define and document backup schedules, retention, and restoration procedures, then follow them. ¹
• Protect backup data with tight access controls and encryption, including backup storage and transfer paths. ¹
• Test restores regularly, document results, and remediate failures with tracked follow-up. ¹

“Information Backup” in HITRUST is an operational control with a simple exam lens: can you restore what matters, within expectations, from protected backups, using repeatable procedures. Auditors tend to focus less on your backup tool and more on whether your backup policy is specific, implemented consistently, and validated through restoration testing. ¹

This requirement is broader than “we have backups.” It covers: (1) taking backup copies of information and software, (2) defining schedules and retention periods, (3) defining and testing restoration procedures, and (4) protecting backups of covered information with access controls and encryption. ¹

For a Compliance Officer, CCO, or GRC lead, the fastest path is to treat backups as a governed service with clear ownership, a small set of standard backup tiers, and evidence that maps directly to each clause of the requirement. Done well, this control reduces downtime and data-loss risk while also closing common audit gaps such as “no restore tests,” “unclear retention,” and “backup access is over-permissioned.” ¹

Regulatory text

HITRUST CSF v11 09.l states: “Backup copies of information and software shall be taken and tested regularly in accordance with the agreed backup policy. Backup schedules, retention periods, and restoration procedures shall be defined, documented, and tested. Backups of covered information shall be protected with appropriate access controls and encryption.” ¹

What the operator must do, clause-by-clause

• “Taken … in accordance with the agreed backup policy”: You need a written backup policy, and your actual backups must match it (scope, frequency, and method). ¹
• “Tested regularly”: You must perform restore testing, not just monitor backup job success. Testing must be repeatable and evidenced. ¹
• “Schedules, retention periods, and restoration procedures … defined, documented, and tested”: Put the “how often,” “how long,” and “how to restore” in writing, then prove you follow and test them. ¹
• “Backups of covered information … protected with … access controls and encryption”: Treat backup repositories as high-value data stores. Limit who can access backups and encrypt backup data at rest and in transit as applicable to your architecture. ¹

Plain-English interpretation

You need a backup program that a skeptical reviewer would trust: you back up covered information and critical software, you can show what gets backed up and when, you keep it for a defined time, you can restore it using documented steps, and you periodically prove restoration works. Backups must be protected like production data, with strong access controls and encryption. ¹

Who it applies to

Entity scope: All organizations assessed against HITRUST CSF. ¹

Operational scope (where this bites in practice):

• Production systems that store, process, or transmit covered information (including regulated data sets and sensitive business data).
• Core infrastructure and software needed to operate or recover services (for example, configuration stores, key systems, and deployment artifacts), because the requirement includes “software.” ¹
• Backup platforms and storage targets, whether hosted internally or by a third party (cloud backup vaults, managed backup services, object storage with immutability features). The control still applies; the evidence just changes. ¹

What you actually need to do (step-by-step)

1) Assign ownership and define “covered information” in backup scope

• Name a service owner for backups (often Infrastructure/SRE) and a control owner in GRC.
• Build a backup inventory: systems, data stores, and SaaS platforms where covered information exists.
• Classify systems into a small set of backup tiers (for example: “mission critical,” “important,” “standard”). Your policy can specify different schedules/retention by tier, as long as it’s clear and followed. ¹

Deliverable: Backup scope register (systems + owners + tier + backup method).

2) Write (or tighten) the backup policy so it can be tested

Your backup policy should be specific enough that a backup admin and an auditor would interpret it the same way:

• Backup schedules by tier/system type (how often backups run; include full vs incremental if relevant).
• Retention periods by tier/system type (how long backups are kept; address both operational restores and longer retention where required).
• Restoration procedures: who can request a restore, who performs it, prerequisites, and verification steps.
• Testing expectations: what gets tested, how results are recorded, and how failures are remediated.
• Security requirements: access controls and encryption for backup storage and transfer paths. ¹

Practical tip: Avoid policy language like “backups are performed regularly.” Use concrete statements you can prove with logs, job reports, and test records. ¹

3) Implement/validate backup automation against the policy

• Configure backup jobs for each in-scope system (or validate existing jobs) and map each job to a system owner.
• Confirm backups include information and software required for recovery. For modern environments, that typically means backing up both data and the configuration/state required to rebuild services. ¹
• Centralize monitoring so failed jobs trigger tickets/incidents and are tracked to closure.

Evidence you’ll need later: job configurations, run logs, and failure remediation records.

4) Lock down backup access (least privilege) and encrypt backup data

Backups are attractive targets because they often contain broad snapshots of covered information. Implement:

• Role-based access to backup consoles and storage, limited to staff who administer backups or perform restores.
• Separation of duties where feasible (for example, restore approvals separate from backup admin actions).
• Encryption for backup data and backup traffic, aligned to how your platform works (native backup encryption, encrypted storage, encrypted replication). ¹

Third party angle: If a third party provides backup services, you still need contractual and technical assurance that access controls and encryption are in place, plus evidence you can obtain during audits.

5) Document restoration procedures that work in your environment

Create “operator-grade” runbooks:

• Preconditions (access, credentials, keys, target environment).
• Restore steps per platform (database restore, file restore, VM snapshot restore, SaaS export restore).
• Validation steps (data integrity checks, application smoke tests).
• Escalation and communications if restores are part of incident response. ¹

6) Test restores regularly and capture results like an auditor will read them

A restore test should answer: What did you restore, from which backup, when, who approved it, did it work, and what did you fix if it didn’t. ¹

Structure each test record:

• System and dataset restored
• Backup identifier/date
• Test date, tester, approver
• Steps executed (reference runbook version)
• Outcome and verification results
• Issues found + corrective actions with ticket links ¹

7) Build the evidence package (continuous, not scramble-time)

Treat backup evidence as a standing audit binder. Daydream can help here by turning the requirement language into an evidence checklist, routing evidence requests to system owners, and keeping restore-test records and screenshots tied to the control for faster assessments and fewer back-and-forth cycles.

Required evidence and artifacts to retain

Keep artifacts that map directly to each clause of HITRUST CSF v11 09.l. ¹

Policy and governance

• Backup policy (approved, versioned)
• Backup scope register / system inventory (in-scope systems + owners + tiers)
• Defined retention schedule and restore testing expectations (in policy or standard) ¹

Technical configuration and operations

• Backup job configurations (screenshots/exports)
• Backup success/failure logs and monitoring reports
• Ticket records for failed jobs and remediation
• Access control evidence (role lists, group membership, access reviews if performed)
• Encryption evidence (settings screenshots, configuration exports, architecture diagrams) ¹

Testing

• Restore test plans or schedule
• Restore test execution records with validation results
• Post-test corrective actions and closure evidence ¹

Third party support (if applicable)

• Contracts/SOW language on backup security and encryption
• Third party attestation materials you’re permitted to share in audits
• Shared responsibility notes: what you back up vs what the third party backs up ¹

Common exam/audit questions and hangups

Expect reviewers to ask:

• “Show me the backup policy and where schedules and retention are defined.” ¹
• “Which systems with covered information are in scope, and how do you know you didn’t miss any?” ¹
• “Prove backups are running as scheduled. What happens on failures?” ¹
• “Show recent restore tests and the evidence that the restores were successful.” ¹
• “Who can access backup repositories? How is that access controlled?” ¹
• “Where is encryption enforced for backups?” ¹

Common hangup: teams provide backup-job success screenshots but cannot show restore tests. HITRUST explicitly requires testing restoration procedures. ¹

Frequent implementation mistakes (and how to avoid them)

1. Policy is vague, so evidence can’t “match.”
   Fix: Put schedules, retention, and restore testing requirements in plain, testable terms; align technical configs to those statements. ¹

2. Backups exist, but restores fail or are unproven.
   Fix: Treat restore tests as mandatory control evidence. Write runbooks, test them, and track defects to closure. ¹

3. Backup storage is over-permissioned.
   Fix: Restrict access to backup consoles and storage to named roles; document who has access and why; remove “convenience” admin grants. ¹

4. Encryption is assumed, not evidenced.
   Fix: Capture configuration evidence that encryption is enabled for backup data and transfer paths relevant to your platform. ¹

5. SaaS data is missed.
   Fix: Include SaaS platforms in your backup inventory and define how exports/backups work, who runs them, and where they are stored and protected. ¹

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this specific HITRUST control, so treat enforcement context as indirect: backup failures typically surface during incidents, ransomware events, disaster recovery exercises, customer audits, or HITRUST assessments. The operational risk is straightforward: inability to restore covered information or critical software can extend outages, increase data loss, and create reportable security events depending on what was impacted. ¹

A practical 30/60/90-day execution plan

First 30 days (stabilize and document)

• Confirm control ownership and define backup scope for covered information. ¹
• Publish or update the backup policy with explicit schedules, retention, restore procedures, and testing expectations. ¹
• Inventory current backup jobs and identify gaps (systems not backed up, unclear retention, missing encryption evidence). ¹

By 60 days (align implementation and security controls)

• Remediate gaps: onboard missing systems; standardize job configs; implement monitoring and ticketing for failures. ¹
• Tighten access controls to backup platforms; document roles and admin access. ¹
• Capture encryption configuration evidence for backup repositories and data transfer paths. ¹

By 90 days (prove restorability and operationalize evidence)

• Run restore tests across representative systems and document results with validation evidence. ¹
• Close restore-test findings through tracked remediation. ¹
• Build a standing evidence package (policy, inventory, logs, access lists, encryption proof, restore-test records). Use Daydream to assign evidence owners, track renewals, and keep the package audit-ready. ¹

Frequently Asked Questions

Do we have to back up “software,” or just data?

The requirement explicitly includes “information and software,” so scope your backups to include what you need to rebuild and operate systems, not only the underlying data. Document what “software” means in your environment and how it is backed up. ¹

What counts as a “test” of backups?

A real restore, using documented restoration procedures, with evidence that the restored system or data is usable. Backup-job success alone does not show restorability. ¹

If a third party runs backups for us, are we still responsible?

Yes. You still need a policy, defined schedules and retention, and evidence of testing and protections. You can satisfy parts of the requirement with third-party evidence, but you must be able to produce it in assessment. ¹

How do we show backups are encrypted without dumping sensitive configs into an audit package?

Provide targeted screenshots or configuration exports that show encryption settings enabled for backup jobs and storage, and redact unrelated sensitive values. Pair this with an architecture diagram that shows where encryption is applied. ¹

What’s the minimum set of artifacts an auditor will accept?

Expect to provide the backup policy, a system-to-backup mapping (inventory), backup execution evidence (logs/reports), access control evidence, encryption evidence, and restore test records with outcomes. ¹

We back up everything nightly. Is that enough?

Only if your policy defines that schedule and retention, and you can prove restores work through regular testing and documented restoration procedures. Auditors assess consistency and evidence, not the slogan “we back up nightly.” ¹

Footnotes

1. HITRUST CSF v11 Control Reference