Access and identity controls

The HITRUST access and identity controls requirement means you must control who can access sensitive systems and data, prove that access is appropriate, and remove access quickly when it’s no longer needed. Operationalize it by implementing role-based access, strong authentication (including MFA where appropriate), and recurring access reviews with audit-ready evidence ¹.

Key takeaways:

• Build an access model (roles, approvals, and least privilege) tied to sensitive systems and data ¹.
• Enforce strong authentication and prove it with configuration evidence, not policy statements ¹.
• Treat access reviews as an evidence-producing control: document scope, results, and remediation, then retain artifacts ¹.

For HITRUST assessments, “access and identity controls” is rarely failed because a team has no IAM tool. It’s failed because access decisions are informal, controls don’t cover all in-scope systems, or the organization can’t produce credible evidence that access was approved, appropriate, and periodically revalidated.

HITRUST is a certifiable framework used by healthcare organizations and service providers. This requirement page focuses on implementation intent: protect sensitive systems and data by controlling identity, authentication, authorization, and ongoing access governance ¹. You’ll see this tested across workforce users, privileged administrators, service accounts, and third-party access paths.

The practical goal for a CCO or GRC lead: define what “sensitive” means for your environment, identify the systems that store/process that data, and establish a repeatable joiner/mover/leaver process with role-based access, MFA, and recurring access recertification that produces clean, reviewable artifacts. Daydream can help you keep the system inventory, access review evidence, and third-party access attestations organized so audits don’t turn into a document scavenger hunt.

Regulatory text

Provided excerpt (summary record): “Baseline implementation-intent summary derived from publicly available framework overviews; licensed standard text is not reproduced in this record.” The summarized requirement is: “Implement identity and access controls for sensitive systems/data.” ¹

Operator interpretation (what you must do):

• Identify the systems in scope (where sensitive data lives or is accessed).
• Ensure every access path is tied to a unique identity (human or non-human).
• Restrict access based on job role and need-to-know (least privilege).
• Use strong authentication controls appropriate to risk (commonly MFA for remote, privileged, and high-risk access).
• Revalidate access on a recurring basis and remove access when it’s no longer justified.
• Keep evidence that proves the control operated, not just that it exists ¹.

Plain-English interpretation of the requirement

The access and identity controls requirement is asking one question: “Can you prove that only the right people (and systems) had the right access to sensitive systems and data, for valid reasons, for the right amount of time?”

That breaks into four operational outcomes:

1. Identity is controlled: no shared accounts for people, clear ownership for service accounts, and a consistent source of truth for users.
2. Authentication is strong: credentials are protected and higher-risk access uses MFA.
3. Authorization is governed: access is approved, role-based where possible, and limited to what’s necessary.
4. Access governance produces evidence: access reviews and deprovisioning are documented and complete ¹.

Who it applies to (entity and operational context)

Entity types typically in scope: healthcare organizations and service providers pursuing HITRUST certification or aligning to HITRUST expectations ¹.

Operational contexts where this control is examined hardest:

• Systems storing or processing regulated or sensitive healthcare data (clinical apps, billing, data warehouses, analytics platforms).
• Remote access (VPN, VDI, SSO portals, admin consoles).
• Privileged access (cloud consoles, EHR admin, database admin, security tooling).
• Third-party access (support vendors, contractors, managed service providers).
• Non-human identities (service accounts, API keys, integration users, RPA bots).

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

1) Define scope: “sensitive systems/data” and access paths

1. Create a list of in-scope applications, infrastructure, and data stores that handle sensitive data.
2. For each system, document:
   • System owner
   • User populations (workforce, admins, third parties, service accounts)
   • Authentication method (SSO, local accounts, LDAP, etc.)
   • Privileged access method (PAM, break-glass, local admin)
3. Map the access paths: direct login, SSO, VPN, APIs, shared admin tools.

Practical tip: start with systems used for patient data and expand to any system that can indirectly access it (ETL tools, backups, logging, support tools). HITRUST assessors will test completeness by asking how you know you didn’t miss any ¹.

2) Establish identity lifecycle controls (joiner/mover/leaver)

1. Define your authoritative source for workforce identities (commonly HRIS) and for contractors/third parties (sponsor-based process).
2. Standardize request and approval:
   • Requestor
   • Business justification
   • Role requested
   • Approver(s): manager + system owner for sensitive systems
3. Leavers: require same-day deprovisioning process for high-risk access in your procedure (time expectations are your policy choice; document what you do and prove you did it).
4. Movers: require access re-evaluation when job function changes.

Evidence focus: tickets, HR termination feeds, access removal logs, and a reconciled list showing the account was disabled/removed in target systems.

3) Implement role-based access control (RBAC) and least privilege

1. Define roles per system (e.g., Billing Clerk, Clinical Viewer, SysAdmin, Security Analyst).
2. For each role, define entitlements:
   • Application roles/groups
   • Data access level
   • Admin actions permitted
3. Prefer group-based assignment over direct permission grants.
4. Build a workflow: access is granted only via approved role assignment.

Where teams get stuck: legacy apps with local accounts. Your mitigation is to document compensating controls (e.g., quarterly local-account review, strong password standards, and restricted admin access) and show evidence that those compensating controls run.

4) Enforce MFA and strong authentication where risk demands it

Implement MFA for:

• Privileged access
• Remote access
• Access to sensitive systems where compromise would expose sensitive data

Then prove it:

• IdP configuration screenshots/exports (MFA policy rules)
• Conditional access rules
• Sample authentication logs showing MFA challenges for relevant populations

Audit hangup: “We have MFA” without showing it’s enforced for the specific system populations in scope. Tie the rule to groups/roles and show the mapping ¹.

5) Control and govern privileged access

1. Identify privileged roles across systems (cloud admin, DB admin, EHR admin).
2. Require named admin accounts (no shared admin for humans).
3. Implement break-glass access with:
   • Approval and logging
   • Post-use review
4. Limit who can create identities, grant roles, and change authentication policies.

Minimum deliverable: a privileged access inventory (admins by system) and evidence that privileged access is reviewed and pruned.

6) Manage non-human identities (service accounts, API keys, integrations)

1. Inventory service accounts and integrations.
2. Assign an owner and purpose for each.
3. Restrict permissions to the minimum needed.
4. Store secrets in a managed vault where feasible; rotate secrets on a defined cadence (set the cadence you can meet, then document and prove it).
5. Monitor use for anomalies and disable unused accounts.

Common gap: service accounts created “temporarily” and never removed. Treat them like privileged identities in access reviews.

7) Run access recertification and remediate findings

1. Define review scope:
   • In-scope systems
   • Privileged access
   • Third-party accounts
   • Dormant accounts
2. For each review cycle:
   • Generate user/access lists from each system (not hand-edited)
   • Send to system owner for attestation
   • Track approvals, removals, and exceptions with rationale
3. Close the loop:
   • Disable/remove unneeded access
   • Document exceptions and compensating controls
   • Retain evidence package per system

Daydream fit: centralize system inventories, reviewer assignments, exported access lists, and remediation tickets so you can produce an audit-ready trail without rebuilding it each cycle.

Required evidence and artifacts to retain

Keep artifacts that show design and operation:

Design evidence

• Access control policy and standards (RBAC, least privilege, MFA expectations)
• Access request/approval procedure (joiner/mover/leaver)
• System inventory identifying sensitive systems/data in scope
• Role definitions and entitlement mappings for key systems ¹

Operating evidence

• Access request tickets showing approvals and provisioning for sampled users
• Termination/deprovisioning evidence (HR trigger + account disablement)
• MFA enforcement configuration (IdP/SSO rules) and logs for sampled authentications
• Privileged access inventory and approvals (PAM logs or admin group change logs)
• Access review packages:
  • System-generated access list exports
  • Owner attestations
  • Remediation tickets and closure proof
• Third-party access approvals and expiration/termination evidence

Common exam/audit questions and hangups

Expect these lines of inquiry:

• “Show your list of systems that contain or access sensitive data. How do you know it’s complete?”
• “Pick five terminated users. Prove their access was removed from SSO and from this application.”
• “Who can grant admin rights? Show approval evidence and change logs.”
• “Demonstrate MFA is enforced for privileged users and remote access.”
• “Show the last access review for this system. Where are the removals tracked?”
• “How do you control service accounts and API keys? Who owns them?” ¹

Hangups that create findings:

• Reviews exist but don’t include privileged access or third-party accounts.
• Access lists are manually edited and not reproducible.
• Exceptions are verbal and undocumented.
• Evidence is scattered across email, chat, and screenshots without context.

Frequent implementation mistakes and how to avoid them

Mistake	Why it fails	Fix
“MFA is enabled” but not enforced for in-scope groups	Assessors test enforcement, not availability	Tie MFA policies to specific roles/groups and keep config evidence
RBAC exists only on paper	Users have direct entitlements outside roles	Convert direct grants to groups; block direct assignment where possible
Access reviews are checkbox exercises	No remediation trail	Require tickets for removals and track closure
Service accounts ignored	High-risk, persistent access	Inventory, assign owners, restrict permissions, review regularly
Third-party access unmanaged	Access persists after engagement	Sponsor-based approvals, expiration dates, and offboarding checklist

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this requirement, so this page does not cite specific cases.

Risk-wise, weak identity and access controls are a common root cause of unauthorized access, data exposure, and inability to prove control effectiveness during audits. For HITRUST, the immediate impact is assessment failure risk or corrective action requirements if evidence is incomplete or controls don’t operate consistently ¹.

Practical 30/60/90-day execution plan

Days 0–30: Establish scope and minimum viable control set

• Build the in-scope system list for sensitive systems/data and name owners.
• Document current authentication methods and admin access paths per system.
• Standardize access request and approval workflow for in-scope systems.
• Turn on or confirm MFA enforcement for privileged and remote access where your IdP supports it; capture configuration evidence ¹.

Deliverables: system inventory, access request workflow, initial MFA enforcement evidence, privileged user list for top systems.

Days 31–60: Normalize RBAC and start governance routines

• Define roles and group mappings for your highest-risk systems.
• Remove direct entitlements that bypass roles (start with privileged access).
• Inventory service accounts and assign owners; document purpose and permissions.
• Run your first access review for privileged access across in-scope systems; open remediation tickets for findings.

Deliverables: role matrix for key systems, service account inventory, privileged access review package with remediation tracking.

Days 61–90: Expand coverage and harden evidence quality

• Extend RBAC and MFA enforcement to remaining in-scope systems or document compensating controls for exceptions.
• Run a full access recertification for at least one major sensitive system (workforce + third parties + service accounts where applicable).
• Add monitoring/log review expectations for access changes (admin group changes, authentication anomalies) and retain samples.
• Centralize evidence packages (system exports, attestations, tickets) in a repository with consistent naming and retention rules.

Deliverables: complete access review package for a major system, updated exception register, evidence repository structure suitable for audit requests.

Frequently Asked Questions

Does HITRUST require MFA everywhere?

The provided HITRUST overview-level source supports implementing identity and access controls, and MFA is a common expectation for high-risk access paths ¹. Operationally, enforce MFA at least for privileged and remote access, and document any exceptions with compensating controls and evidence.

What counts as “sensitive systems/data” for scoping?

Treat any system that stores, processes, or can access sensitive healthcare data as in scope, plus systems that can be used to reach those systems (backup, admin, integration tooling). Write down your scoping logic and keep a system list with owners ¹.

We have legacy apps without SSO. Can we still pass?

Yes, if you can show controlled identities, strong authentication controls appropriate to the app, and consistent access reviews with remediation evidence. Document the exception, apply compensating controls, and retain proof they operated.

How should we handle third-party access?

Require a business sponsor, time-bound approvals, and a clear offboarding step when the engagement ends. Include third-party accounts in access reviews and keep the approvals and disablement evidence.

What do assessors usually ask for as evidence?

They typically request access lists, approvals, proof of MFA enforcement, access review packages, and termination/deprovisioning samples that tie a person to account removal. Keep system-generated exports and ticket trails, not just screenshots.

Can Daydream help with this requirement?

Yes, if you need a structured way to track in-scope systems, control owners, access review cycles, third-party attestations, and evidence packages. The goal is faster audits and fewer evidence gaps, not more paperwork.

Related compliance topics

• 2025 SEC Marketing Rule Examination Focus Areas
• Access Control (AC)
• Access control and identity discipline
• Access control management
• Access management

Footnotes

1. HITRUST certification overview