Testing and Revision Procedures: Testing the contingency plan and recording the result

45 CFR 164.308(a)(7)(ii)(D) covers testing and revision procedures. In most assessments the control itself is present and the record proving it is not, which is why this requirement produces findings at organizations that are, in practice, doing the work.

What the rule says

Testing and revision procedures (Addressable). Implement procedures for periodic testing and revision of contingency plans.

That is the text of 45 CFR 164.308(a)(7)(ii)(D). 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 164.308(a)(7)(ii)(D) 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 periodically test its contingency, recovery, and continuity plans and document the results?
• Does the organization test a restore from backup on a defined schedule and confirm the recovered data is complete and usable?
• Does the organization keep at least one backup copy of its ePHI that an attacker who gains administrator access cannot alter or delete, such as an offline, air-gapped or immutable (write-once) copy, and test restoring from it?

Ownership usually sits with the security official, 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 schedule for testing contingency, disaster recovery, and business continuity plans through scenarios such as outages, natural disasters, or technical failures.
2. Define test methods, roles, and success criteria.
3. Document test results, gaps, and corrective actions.
4. Update the plans based on lessons learned.
5. Set a schedule for restoring from backup, covering each system that holds sensitive data.
6. Restore to a separate environment and check that the recovered data is complete and the application runs on it.

Where else this maps

The questions behind 45 CFR 164.308(a)(7)(ii)(D) also map to HHS 405(d) HICP (2023 Edition) CSP 4 and NIST SP 800-66 Rev. 2 5.1.7, which are voluntary guidance rather than law; following them 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 types that satisfy it are record and report. 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 164.308(a)(7)(ii)(D) that means dated records of each occurrence, not a description of the process and a dated report with the period it covers and who reviewed it. If the only evidence is that someone knows how this works, you have a practice and not a record.
• Put a name on it. Your security official should be recorded as the owner. Where the work is done by someone else, say so in the document: the split between who owns it and who performs it is where the trail usually breaks. A control with no owner stops working the month the person who quietly maintained it changes roles, and nobody notices.
• Review it on a fixed date, not when you remember. In our question bank this is weighted Critical: a gap here is raised as a critical finding (a partial answer as high). Put the review on the calendar with an owner, and keep the dated output of each one.
• 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.

If 45 CFR 164.308(a)(7)(ii)(D) is new to you, the useful first step is not a policy template. It is writing down what you already do, dating it, and naming an owner. That turns an undocumented practice into evidence, and it usually reveals the real gap.

Related requirements

• Emergency Mode Operation Plan: Emergency mode operation when systems are down
• Applications and Data Criticality Analysis: Ranking applications and data by criticality
• Disaster Recovery Plan: A disaster recovery plan sized to your practice

References

• 45 CFR 164.308(a)(7)(ii)(D), in 45 CFR 164.308 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).