Compliance assurance and control testing

HITRUST certification depends on more than having policies and tools in place. You have to prove that controls operate as intended across your scoped systems, teams, and third parties, and that you can produce evidence on demand. This is what “compliance assurance and control testing” looks like in practice: test control operation and maintain assurance evidence for certification ¹.

For a Compliance Officer, CCO, or GRC lead, the fast path is to treat control testing like an internal audit function sized to your organization: define test procedures, run them on a predictable schedule, store evidence in a way that matches the control, and remediate failures with the same discipline you would apply to a production outage. The “gotcha” is rarely the control itself; it’s missing, inconsistent, or unactionable evidence and a lack of traceability from requirement → control → test → artifact → exception → remediation → retest.

This page gives you requirement-level implementation guidance you can execute quickly: who this applies to, what to do step-by-step, what to retain, common auditor questions, and a practical execution plan. Where platform support helps, Daydream is a natural place to standardize testing workflows and evidence collection across control owners.

Requirement overview (plain-English interpretation)

Plain-English requirement: You must periodically verify (test) that your HITRUST-scoped controls work in real operations, and you must maintain evidence of those tests that is sufficient for HITRUST certification ¹.

What “test” means operationally:

• You don’t just confirm a control exists (design). You confirm it ran, consistently, for the in-scope environment (operation).
• You define how you know it ran (test steps) and what proof you will keep (artifacts).
• You record exceptions, fix them, and prove the fix held (retest + closure evidence).

What “maintain assurance evidence” means:

• Evidence is organized, retrievable, complete, and mapped to the control requirement.
• Evidence covers the audit period and scope, not a random sample of convenience.
• Evidence shows who did what, when, against what population, and what the result was.

Who it applies to (entity and operational context)

This requirement applies to organizations pursuing or maintaining HITRUST certification, including:

• Healthcare organizations (providers, payers, health tech companies handling regulated health data).
• Service providers that store, process, transmit, or secure healthcare data for customers ¹.

Operationally, it applies wherever controls exist in your HITRUST scope, such as:

• Security operations (identity, logging, vulnerability management)
• IT operations (change management, backups, endpoint management)
• Privacy/compliance (training, risk analysis, incident response)
• Product/engineering (SDLC, access controls, environment segregation)
• Third-party risk management (due diligence, monitoring, contract controls) when third parties are in scope

Regulatory text

Provided excerpt (summary-level, non-licensed): “Baseline implementation-intent summary derived from publicly available framework overviews; licensed standard text is not reproduced in this record.” The implementation intent is: “Test control operation and maintain assurance evidence for certification.” ¹

What the operator must do:

1. Define control tests that demonstrate operating effectiveness for each in-scope requirement.
2. Execute testing on a planned cadence that matches how the control operates (event-based, continuous, periodic).
3. Retain evidence that a reviewer can use to re-perform or validate the test.
4. Manage exceptions through documented remediation and retesting until closure.

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

1) Set scope and ownership for testing

• Confirm HITRUST scope: systems, environments, business units, locations, and third parties that are in scope for certification ¹.
• For each in-scope control, assign:
  • Control owner (runs the control)
  • Evidence owner (produces artifacts, often same as control owner)
  • Tester (GRC, internal audit, or a delegated reviewer separate from execution where feasible)

Output: A scoped control inventory with named owners and a single source of truth (spreadsheet is acceptable; a GRC tool is better).

2) Build a control testing plan (the “how”)

For each control, document:

• Control statement (what must happen)
• Population (what the control applies to: systems, users, tickets, logs)
• Frequency (how often it runs)
• Test method (inquiry, observation, inspection, re-performance)
• Sampling approach (how you select items when population is large)
• Pass/fail criteria (objective thresholds you define)
• Evidence list (screenshots, exports, tickets, logs, reports)

Practical tip: write test steps so a new tester can follow them without tribal knowledge.

Output: Control test procedures (one per control or per control family).

3) Create an evidence production workflow that control owners can follow

Most programs fail because evidence is ad hoc. Standardize it:

• Use a monthly/quarterly evidence request calendar aligned to control frequencies.
• Provide evidence templates (change review checklist, access review sign-off, vulnerability exception record).
• Define naming conventions (control ID/name + period + system + owner) and storage location.
• Require context with every artifact: scope, timeframe covered, system name, and who generated it.

Where Daydream fits naturally: centralizing evidence requests, reminders, and a consistent control-to-evidence mapping so you can answer “show me proof” without Slack archaeology.

Output: Evidence calendar + evidence templates + repository structure.

4) Execute tests and document results like an auditor will read them

For each test:

• Record test date, tester, control owner consulted (if any)
• Document population and sample selection (even if sample is “all items”)
• Attach or link evidence artifacts
• Write a result that is clear and falsifiable:
  • Pass (meets criteria)
  • Pass with notes (minor documentation gap, no control failure)
  • Fail (control did not operate, operated inconsistently, or evidence cannot prove operation)

Output: Completed test worksheets with linked evidence.

5) Track deficiencies and remediate to closure (with retest)

Treat a control failure as a managed issue:

• Log a deficiency with:
  • Description (what failed)
  • Root cause (process gap, tooling gap, training gap)
  • Risk statement (what could happen because of the failure)
  • Owner and due date
  • Interim compensating control (if applicable)
• Maintain a remediation plan with measurable steps.
• Require closure evidence (ticket showing config change, updated procedure, completed training roster, etc.).
• Retest the control after remediation and attach retest evidence.

This aligns to the recommended control: run control testing schedules and track deficiency remediation ¹.

Output: Deficiency log + remediation tickets + retest results.

6) Report status to leadership and keep the certification narrative coherent

Create a simple operating rhythm:

• A dashboard (even a table) showing: tests due, tests completed, failures, remediation in progress, overdue items.
• A monthly review with control owners for bottlenecks.
• A quarterly readout to executives: top recurring control failures, systemic fixes, and upcoming audit milestones.

Required evidence and artifacts to retain (audit-ready checklist)

Maintain artifacts in a way that supports your certification assessment ¹. Typical evidence includes:

Core artifacts

• Control inventory and scope statement (systems, org units, third parties)
• Control test plan and procedures
• Completed test results with tester sign-off
• Evidence files/exports/screenshots mapped to each test
• Deficiency register with remediation status
• Remediation and closure evidence (tickets, change records, approvals)
• Retest documentation

Supporting artifacts (commonly requested)

• Access reviews and approvals (system-generated reports + sign-off)
• Change management tickets with approvals and test results
• Vulnerability scans and remediation tracking
• Logging/monitoring configuration proof and alert triage records
• Training completion records (if the control requires training)

Retention rule of thumb (guidance): keep evidence for at least the full certification audit period plus enough lookback to demonstrate consistency, then align to your internal retention policy and contracts.

Common exam/audit questions and hangups

Expect assessors to probe these areas ¹:

• “Show me the test procedure.” If you can’t explain how you tested, evidence alone may not carry you.
• “How did you pick the sample?” Weak sampling logic is a common finding.
• “Does this evidence match the scope and period?” Out-of-scope screenshots and old exports get rejected.
• “Who reviewed and approved?” Tests without reviewer identity and date look informal.
• “What happened when it failed?” No deficiency record implies the test wasn’t taken seriously.

Frequent implementation mistakes (and how to avoid them)

Mistake	Why it fails in certification	Fix
Evidence is scattered across email/Slack	You can’t prove completeness or retrieve quickly	Central repository + naming convention + evidence calendar
Testing only checks “policy exists”	HITRUST expects operational proof for certification 1	Add operating effectiveness tests (tickets, logs, system reports)
No documented population	Assessors can’t tell what was covered	Record population source (CMDB, asset inventory, IAM export)
Exceptions are “fixed” verbally	No traceability from fail → fix → retest	Deficiency log + remediation tickets + retest evidence
Control owners don’t know what to provide	Late or low-quality artifacts	Evidence templates + training + office hours

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this requirement. Operationally, the risk is still material: weak control testing increases the chance you miss control failures that can lead to security incidents, customer contract breaches, and certification delays or qualification issues. For teams selling into healthcare, certification slippage can also stall deals when customers require HITRUST evidence in procurement ¹.

Practical 30/60/90-day execution plan

Days 1–30: Stand up the minimum viable testing program

• Confirm HITRUST scope and list in-scope systems and third parties ¹.
• Build control inventory with owners and evidence owners.
• Draft testing procedures for the highest-risk controls first (access, change, vulnerability, logging).
• Set up evidence repository structure and naming convention.
• Start a deficiency log and define severity tiers (your definitions).

Days 31–60: Run the first testing cycle and fix what breaks

• Execute tests for priority controls and document results.
• Hold weekly triage for failed tests and missing evidence.
• Open remediation tickets with owners; require closure evidence.
• Add missing evidence templates based on what teams struggled to produce.
• Start a simple dashboard for leadership visibility.

Days 61–90: Normalize cadence and harden audit readiness

• Expand testing coverage to remaining in-scope controls.
• Retest remediated controls and close deficiencies with proof.
• Perform a “mock evidence pull”: pick a control set and retrieve everything an assessor would request within a short time window.
• Lock your operating rhythm (monthly evidence collection, quarterly reporting).
• If tooling gaps remain, implement Daydream workflows to standardize evidence requests, mapping, and deficiency tracking across control owners.

Frequently Asked Questions

How often do we need to test controls to meet the compliance assurance and control testing requirement?

Test on a cadence that matches how the control operates (continuous, periodic, or event-based) and that supports your HITRUST certification assessment ¹. Document the rationale for each frequency in your testing plan.

What counts as “good evidence” for HITRUST control testing?

Good evidence is specific, dated, scoped, and reproducible: it shows the control ran for the in-scope system and time period and includes who performed and reviewed the activity. Prefer system-generated records (exports, logs, tickets) over informal attestations.

Do we need separation of duties between the control owner and the tester?

HITRUST materials emphasize assurance and evidence for certification, but this record does not prescribe a specific organizational model ¹. Where separation is not feasible, add compensating review (manager or GRC review) and document it.

How do we handle third parties in control testing?

If a third party is in your HITRUST scope, define what you will test directly versus what you will obtain from the third party (reports, attestations, contractual evidence). Keep the mapping clear: requirement → control → third-party obligation → received evidence.

What should we do when a control test fails close to the certification assessment?

Log the deficiency, implement a remediation plan, document compensating controls (if any), and retest as soon as the fix is in place. Keep a tight narrative with dated artifacts so the assessor can see progression from failure to closure ¹.

We have evidence, but it’s messy. How do we make it audit-ready quickly?

Standardize naming, folders, and an evidence index that maps each control to required artifacts and test results. A GRC workflow tool like Daydream can reduce scramble by assigning evidence tasks to owners, tracking status, and keeping artifacts tied to the control and period.

Related compliance topics

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

Footnotes

1. HITRUST certification overview