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HIPAA compliance TODO tracker

Last 1 Enterprises LLC / LastVet Status: Consolidated index of numbered scaffold TODOs (2026-08-26). Purpose: Queryable list for incremental Ryan fills during SBIR crunch and external triggers (BA verification, Corgi renewal, WSGR review, etc.).

Scaffolds merged with open TODOs (PRs #36, #38, #39). Not a compliance attestation.

Do not sync to internal-docs wiki until substantive review pass (post-SBIR).

Buckets 2–3 (verify + evidence, technical build): do not start without explicit Ryan approval.


Summary

Bucket Document Section Count PR
1a HIPAA_ARCHITECTURE.md §4 12 #36
1b HIPAA_RISK_ANALYSIS.md §9 10 #38
1c HIPAA_POLICIES/ §7 per policy 56 #39
Total 78

This index lists numbered / §7 bullet items only. Additional inline TODO (Ryan) and [Depends on 1a §4 TODO N] markers remain in the source documents (189+ inline markers total).

Note: 1a-11 (approve 1b+1c kickoff) was satisfied by merge of #38 and #39; keep for audit trail or mark Done when convenient.


Quick index

ID Bucket Item (abbrev.) Status
1a-01 1a Confirm ePHI column for every TODO row in §1 (especially lastvet-edge logs, observability Loki, … Open
1a-02 1a Confirm NAS inventory: WD My Cloud model (EX4100?), what datasets are synced, whether backup dumps w… Open
1a-03 1a Confirm network gear in service: SonicWall vs Orbi vs Netgate 5200 actual production path; cloudflar… Open
1a-04 1a AWS residual risk: Are imaging S3 buckets / RDS empty of any veteran-class data? Keep or terminate B… Open
1a-05 1a Imaging cutover truth: Prod/staging IMAGING_STORAGE_MODE; iOS envelope client shipped or not; any … Open
1a-06 1a VA production timeline: Case #00015000 status for when “synthetic only” claim ends (gates real ePHI … Open
1a-07 1a Egress inventory: Email, support tools, analytics, Comp AI, status page: which can see ePHI identifi… Open
1a-08 1a Colo / Feb 2027 move: Update physical custody narrative (Muster colo BAA question) if still planned. Open
1a-09 1a Owner column: Assign operational owners beyond “Ryan / LastVet” where someone else is accountable. Open
1a-10 1a WSGR review packet: After TODOs filled, which excerpt of this file + POSTURE.md goes to privacy spec… Open
1a-11 1a Approve Bucket 1b + 1c kickoff only after this file’s TODOs are closed or explicitly deferred with d… Done (superseded)
1a-12 1a Muster: Ensure hipaa-security-rule-readiness-3-bucket-compliance-work-plan points at `docs/complia… Open
1b-01 1b Reconcile with 1a: When HIPAA_ARCHITECTURE.md §4 TODOs close, update As… Open
1b-02 1b Assign L/I for all risk register rows (§6); recalculate levels after real PHI admission. Open
1b-03 1b Complete threat–vulnerability matrix for full vuln catalog (§4). Open
1b-04 1b Tailscale ACL documentation — closes V-A-NET-08-01 gap. Open
1b-05 1b Provider session / MFA policy — closes V-A-EP-03-01 and R-017 mitigation detail. Open
1b-06 1b Backup/DR test evidence — R-005, R-006 treatment rationale. Open
1b-07 1b AWS residual verification — R-011 [Depends on 1a §4 TODO 4]. Open
1b-08 1b Egress / email template review — R-014 [Depends on 1a §4 TODO 7]. Open
1b-09 1b WSGR packet: Excerpt §6–§8 + POSTURE.md for privacy team with provider agreement (align 1a §4 TODO 1… Open
1b-10 1b Annual cadence: Set evaluation schedule per §164.308(a)(8) (see 1c 08-evaluation.md). Open
1c-01-01 1c Define sanction policy workflow and documentation storage. Open
1c-01-02 1c Define information system activity review checklist (Loki, Postgres, consent_audit_log, UptimeRobot)… Open
1c-01-03 1c Link risk register treatment decisions to Muster tracker items. Open
1c-02-01 1c Name Security Officer and deputy in metadata. Open
1c-02-02 1c Define escalation to counsel for breach / OCR matters. Open
1c-03-01 1c Define onboarding/offboarding checklist (Tailscale, GitHub, BWS, Grafana). Open
1c-03-02 1c Document Robert and any future workforce roles vs contractor status. Open
1c-03-03 1c Background check policy if required for workforce with ePHI access. Open
1c-04-01 1c Access request / approval workflow for operators. Open
1c-04-02 1c Minimum necessary matrix by role (provider, support, engineering). Open
1c-04-03 1c Reconcile with 1a asset owners (§4 TODO 9). Open
1c-05-01 1c Define training content aligned with LastVet two-data-plane and consent model. Open
1c-05-02 1c Document training records retention. Open
1c-05-03 1c Provider-facing security expectations (separate from workforce?) — coordinate with WSGR provider agr… Open
1c-06-01 1c Draft incident response playbook referencing observability VM and Tailscale isolation. Open
1c-06-02 1c Define breach vs security incident threshold with WSGR. Open
1c-06-03 1c Tabletop exercise schedule. Open
1c-07-01 1c RTO/RPO for Postgres and imaging. Open
1c-07-02 1c Restore drill evidence (Depends on 1a §4 TODO 2 — NAS contents). Open
1c-07-03 1c Emergency operations if R940 unavailable. Open
1c-08-01 1c Define evaluation calendar and responsible party. Open
1c-08-02 1c Comp AI / audit evidence packing workflow. Open
1c-08-03 1c Trigger evaluation on VA prod access approval (#00015000). Open
1c-09-01 1c BAA inventory table with vendor, status, renewal date. Open
1c-09-02 1c Provider BAA template alignment with WSGR draft. Open
1c-09-03 1c Confirm whether colo move requires facility BAA (1a §4 TODO 8). Open
1c-10-01 1c Facility access log or badge policy if colo. Open
1c-10-02 1c Visitor escort procedures. Open
1c-10-03 1c iDRAC physical port access controls. Open
1c-11-01 1c Screen lock / timeout requirements. Open
1c-11-02 1c Prohibition on local PHI storage on operator devices except approved tools. Open
1c-11-03 1c Provider workstation guidance in provider agreement. Open
1c-12-01 1c Define minimum OS patch cadence for operator machines. Open
1c-12-02 1c Lost device procedure. Open
1c-13-01 1c Disk decommission / wipe procedure for R940 drives. Open
1c-13-02 1c AWS volume retirement checklist (R-011). Open
1c-13-03 1c Backup tape/USB policy if ever used. Open
1c-14-01 1c Session timeout values for provider portal. Open
1c-14-02 1c Break-glass procedure for DB owner access. Open
1c-14-03 1c Unique ID mapping for workforce vs service accounts. Open
1c-15-01 1c Define audit log review procedure (link to 01-admin-security-management-process). Open
1c-15-02 1c Clock sync / NTP standard. Open
1c-15-03 1c Alert on audit pipeline failure. Open
1c-16-01 1c Checksum or versioning policy for critical documents if not already enforced. Open
1c-16-02 1c Integrity monitoring for MinIO objects. Open
1c-17-01 1c MFA policy for Tailscale and BWS. Open
1c-17-02 1c Provider identity proofing alignment with onboarding. Open
1c-17-03 1c Service account rotation schedule. Open
1c-18-01 1c Verify MinIO TLS configuration in ops runbook. Open
1c-18-02 1c Certificate expiry monitoring ownership. Open
1c-18-03 1c Client-side certificate pinning if ever required for mobile. Open
1c-19-01 1c Subcontractor flow-down template. Open
1c-19-02 1c BAA termination and data return procedure. Open
1c-19-03 1c Angel/Neon and other org boundaries — confirm out of LastVet BAA scope. Open
1c-20-01 1c Counsel confirmation to file in compliance folder. Open
1c-20-02 1c If status changes, add plan documents and certification requirements. Open

Detailed entries

1a-01

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Confirm ePHI column for every TODO row in §1 (especially lastvet-edge logs, observability Loki, angel-local, n8n-r940, auth-last1id / sovereign-db-last1id, Mac/agent-01, Robert device).

1a-02

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Confirm NAS inventory: WD My Cloud model (EX4100?), what datasets are synced, whether backup dumps will contain ePHI at first real veteran, R730xd delivery/install plan.

1a-03

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Confirm network gear in service: SonicWall vs Orbi vs Netgate 5200 actual production path; cloudflared still required for which hostnames.

1a-04

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: AWS residual risk: Are imaging S3 buckets / RDS empty of any veteran-class data? Keep or terminate BAA coverage narrative for auditors.

1a-05

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Imaging cutover truth: Prod/staging IMAGING_STORAGE_MODE; iOS envelope client shipped or not; any remaining S3 presigned clients.

1a-06

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: VA production timeline: Case #00015000 status for when “synthetic only” claim ends (gates real ePHI admission).

1a-07

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Egress inventory: Email, support tools, analytics, Comp AI, status page: which can see ePHI identifiers.

1a-08

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Colo / Feb 2027 move: Update physical custody narrative (Muster colo BAA question) if still planned.

1a-09

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Owner column: Assign operational owners beyond “Ryan / LastVet” where someone else is accountable.

1a-10

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: WSGR review packet: After TODOs filled, which excerpt of this file + POSTURE.md goes to privacy specialists with the provider agreement / BAA draft.

1a-11

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Done (superseded by PR #38/#39 merge)
  • Item: Approve Bucket 1b + 1c kickoff only after this file’s TODOs are closed or explicitly deferred with dates.

1a-12

  • Bucket: 1a
  • Source: HIPAA_ARCHITECTURE.md §4
  • Merged via: PR #36
  • Status: Open
  • Item: Muster: Ensure hipaa-security-rule-readiness-3-bucket-compliance-work-plan points at docs/compliance/HIPAA_ARCHITECTURE.md (item may need filing if missing from tracker).

1b-01

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Reconcile with 1a: When HIPAA_ARCHITECTURE.md §4 TODOs close, update Asset ID ePHI flags, vulnerability rows, and matrix cells marked ○ or "Blocked on 1a".

1b-02

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Assign L/I for all risk register rows (§6); recalculate levels after real PHI admission.

1b-03

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Complete threat–vulnerability matrix for full vuln catalog (§4).

1b-04

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Tailscale ACL documentation — closes V-A-NET-08-01 gap.

1b-05

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Provider session / MFA policy — closes V-A-EP-03-01 and R-017 mitigation detail.

1b-06

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Backup/DR test evidence — R-005, R-006 treatment rationale.

1b-07

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: AWS residual verification — R-011 [Depends on 1a §4 TODO 4].

1b-08

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Egress / email template review — R-014 [Depends on 1a §4 TODO 7].

1b-09

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: WSGR packet: Excerpt §6–§8 + POSTURE.md for privacy team with provider agreement (align 1a §4 TODO 10).

1b-10

  • Bucket: 1b
  • Source: HIPAA_RISK_ANALYSIS.md §9
  • Merged via: PR #38
  • Status: Open
  • Item: Annual cadence: Set evaluation schedule per §164.308(a)(8) (see 1c 08-evaluation.md).

1c-01-01

1c-01-02

1c-01-03

1c-02-01

1c-02-02

1c-03-01

1c-03-02

1c-03-03

1c-04-01

1c-04-02

1c-04-03

1c-05-01

1c-05-02

1c-05-03

1c-06-01

1c-06-02

1c-06-03

1c-07-01

1c-07-02

1c-07-03

1c-08-01

1c-08-02

1c-08-03

1c-09-01

1c-09-02

1c-09-03

1c-10-01

1c-10-02

1c-10-03

1c-11-01

1c-11-02

1c-11-03

1c-12-01

1c-12-02

1c-13-01

1c-13-02

1c-13-03

1c-14-01

1c-14-02

1c-14-03

1c-15-01

1c-15-02

1c-15-03

1c-16-01

1c-16-02

1c-17-01

1c-17-02

1c-17-03

1c-18-01

1c-18-02

1c-18-03

1c-19-01

1c-19-02

1c-19-03

1c-20-01

1c-20-02