Maintenance Records: Maintenance records for security-relevant repairs

If you have been asked for evidence of maintenance records, the requirement behind the question is 45 CFR 164.310(a)(2)(iv). What follows is what it says, what satisfies it, and where organizations usually come up short.

What the rule says

Maintenance records (Addressable). Implement policies and procedures to document repairs and modifications to the physical components of a facility which are related to security (for example, hardware, walls, doors, and locks).

That is the text of 45 CFR 164.310(a)(2)(iv). Read it closely: it describes an outcome to achieve, not a product to buy, which is why two practices of the same size can satisfy it in different ways and both be right.

This is an addressable implementation specification, and addressable does not mean optional. Under 45 CFR 164.306(d)(3) you assess whether the specification is reasonable and appropriate in your environment, and then either implement it or, if implementing it is not reasonable and appropriate, document why and implement an equivalent alternative measure if that is reasonable and appropriate. The documented reasoning is itself part of the requirement, so an undocumented decision to skip it is the finding.

What this looks like in practice

In an assessment, 45 CFR 164.310(a)(2)(iv) is not one question. It resolves into several, and each one is really asking for different evidence. These are among the questions asked about it:

• Does the organization authorize, track, and log security-related repairs and modifications to the physical components of its facilities, or, where it has determined that this safeguard is not reasonable and appropriate, documented that determination and implemented an equivalent alternative measure (45 CFR 164.306(d)(3))?

Ownership usually sits with whoever controls building access, though the evidence is often produced by someone else, which is where the trail breaks. A control that works but has no owner tends to stop working the month the person who quietly maintained it changes roles.

Who this applies to

Every covered entity and every business associate, at any size. 45 CFR 164.306(b) allows flexibility of approach, so a two-provider practice and a hospital system may implement this differently and both comply. What flexibility does not allow is skipping the decision: the smaller the organization, the more the written reasoning carries the weight, because there is no scale of operation to make the control self-evident.

Building it, in order

These steps are one way to meet it, drawn from our question bank. Unless a step names a provision, the Security Rule does not require that particular measure: 45 CFR 164.306(b)(1) lets you use any security measures that allow you to reasonably and appropriately implement the standards and implementation specifications, chosen with the factors in 45 CFR 164.306(b)(2).

The sequence below is the order that produces evidence as a by-product rather than as a separate documentation exercise:

1. Establish a procedure requiring authorization before any security-related repair or modification to facility components (such as doors, locks, walls, and hardware). Where the organization determines this safeguard is not reasonable and appropriate, record that determination and the equivalent alternative measure implemented, as 45 CFR 164.306(d)(3) provides.
2. Record each repair and modification with date, description, performer, and authorizing party.
3. Retain maintenance records for the six-year period 45 CFR 164.316(b)(2)(i) requires.
4. Review records periodically to confirm completeness and detect unauthorized changes.

Where else this maps

The questions behind 45 CFR 164.310(a)(2)(iv) also map to NIST SP 800-66 Rev. 2 5.2.1, which is voluntary guidance rather than law; following it does not by itself establish compliance with any law. That matters for scoping: the same evidence can be written once and referenced from each, rather than rewritten per framework.

Evidence an assessor asks for

For this requirement the evidence type that satisfies it is a procedure. The distinction matters more than it looks: a policy states what you intend to do, a procedure states how, and a record proves it happened on a date. Auditors ask for all three, and a practice that has written the first two often has nothing for the third.

Date every document and keep the superseded versions. 45 CFR 164.316(b)(2)(i) requires the documentation 164.316(b)(1) calls for (the Security Rule policies and procedures, and the written record of any action, activity or assessment the Security Rule requires to be documented) to be retained for six years from the date of its creation or the date when it last was in effect, whichever is later, so a policy you replaced two years ago is still part of the record.

Where this usually goes wrong

The most common failure here is treating addressable as optional. A practice decides the specification does not fit, implements nothing, and writes nothing down. At assessment the answer to "why not" is a verbal explanation, which is not evidence. The second most common failure is the opposite: implementing an alternative that works, and still not recording the reasoning, so the control looks accidental.

What to do about it

• Produce the evidence, not the intention. For 45 CFR 164.310(a)(2)(iv) that means a step-by-step procedure someone unfamiliar with the task could follow. If the only evidence is that someone knows how this works, you have a practice and not a record.
• Put a name on it. Whoever controls building access should be recorded as the owner. A control with no owner stops working the month the person who quietly maintained it changes roles, and nobody notices.
• Set a review cadence and keep the evidence of each review. An annual date with a dated output is a common floor; what fails an assessment is a control implemented once and never re-checked against a changed environment.
• If you decide not to implement it, write the decision down. Addressable is not optional: under 45 CFR 164.306(d)(3) the documented assessment IS part of the requirement, so an undocumented decision to skip it is the finding, and a working alternative with no recorded reasoning looks accidental.

None of this makes maintenance records harder than it is. The requirement asks for a decision, an implementation, and a record. Organizations that struggle at assessment time are rarely the ones without controls; they are the ones that cannot show when a control started or who owns it now.

Related requirements

• Access Control and Validation Procedures: Validating who gets into clinical space
• Workstation Use: Workstation use rules for shared clinical machines
• Facility Security Plan: A facility security plan that matches the building

References

• 45 CFR 164.310(a)(2)(iv), in 45 CFR 164.310 on eCFR. Quoted text verified against the eCFR text current as of 2026-10-06.
• The Required and Addressable designations are defined at 45 CFR 164.306(d).
• Crosswalk references in this post are the mappings in our question bank, and are not verified against the published text of those standards.
• This post describes what a requirement asks for and what evidence documents it. It is not legal advice, and your counsel owns the conclusion. State law may impose additional obligations; HIPAA preempts a State law only where it is contrary to HIPAA (45 CFR 160.202, 160.203).