Comprehensive HIPAA compliance posture assessment for agent and API contexts. Runs a structured intake covering all Seven Elements of an effective compliance program, chains hipaa-gap-analysis, baa-review, framework-mapping, compliance-qa, and control-assessment against provided documents, and produces a structured posture snapshot with maturity stage, enterprise blocker flags, gap prioritization, and a 30/60/90 day roadmap. Compatible with any agent context that has access to the rote-compliance-toolkit tools — via Claude Code plugin, Rote MCP server, or direct API integration.
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Comprehensive HIPAA compliance posture assessment for agent and API contexts. Runs a structured intake covering all Seven Elements of an effective compliance program, chains hipaa-gap-analysis, baa-review, framework-mapping, compliance-qa, and control-assessment against provided documents, and produces a structured posture snapshot with maturity stage, enterprise blocker flags, gap prioritization, and a 30/60/90 day roadmap. Compatible with any agent context that has access to the rote-compliance-toolkit tools — via Claude Code plugin, Rote MCP server, or direct API integration.
argument-hint
Start the compliance posture intake — answer orientation questions, then optionally provide documents for analysis
allowed-tools
Read, Glob, Grep, WebFetch, WebSearch, Write
version
1.1
author
Rote Compliance
license
Apache-2.0
Compliance Posture Intake
Purpose
Guide a non-technical user through a structured compliance posture assessment.
Combine their self-reported answers with analysis of any compliance documents
they share. Deliver a polished Word document they can share with their team,
bring to a consultation, or use to seed a Rote account.
This skill runs all analysis inline by default. Do not rely on external tool invocations unless they are available in your agent context.
Note for Agent Contexts: This skill runs all analysis inline by default.
However, if you are running in an agent context (like Claude Code, Rote MCP,
or a custom agent) with access to the rote-compliance-toolkit tools, you may
optionally chain those tools for document analysis (Step 3) instead of doing it inline.
The analytical methodology for each document type is embedded in Step 3 below.
How to Run This Skill
Work conversationally. Do not present the full question list upfront.
Lead the user through the assessment as a structured conversation —
each step flows naturally from the last.
Before beginning, say:
"I'll guide you through a compliance posture assessment. It takes about
15 minutes and covers your policies, training, oversight structure, risk
management, and incident response. At the end, I'll produce a report you
can share with your team or bring to a consultation.
Let's start with some context about your organization."
Step 1 — Orientation
Ask Group A and Group B as two separate conversational exchanges.
Do not number the questions aloud — ask them naturally as a grouped set.
Group A — Organizational context
Ask all eight together in a single message, formatted as a brief list:
"A few quick questions to set the context:
Briefly describe what your product or service does — what problem it solves
and what types of data or workflows it touches. (A sentence or two is fine.)
What is your organization's role under HIPAA — are you a Covered Entity,
a Business Associate, or both? (If you're not sure, just say so.)
Roughly how many employees handle patient data, directly or indirectly?
What stage is your company at? (Pre-revenue, early growth Series A/B,
established Series B+, or enterprise)
Who is your primary healthcare customer? (Small practices, mid-market
health systems, enterprise health systems, payers, or multiple)
Which compliance frameworks are you expected to meet? (HIPAA is the
baseline — are HITRUST, SOC 2, NIST, or ISO 27001 also on the table?)
What's your main goal with this assessment today?
Do you have any compliance documents you'd like me to analyze? (Policies,
a BAA, a risk assessment, training records, or a state license or business
registration — any combination is fine.)"
Group B — Risk profile
After receiving Group A answers, ask Group B as a brief follow-up:
"A few more quick ones:
Does your product handle any extra-sensitive categories of health data —
behavioral health records, substance use disorder data, HIV/AIDS status,
or pediatric records?
Have you completed any third-party compliance certifications — SOC 2,
HITRUST, or ISO 27001?
Do any subcontractors, offshore developers, or outsourced partners have
access to patient data or the environments that contain it?
In which states do you operate or serve customers? Every state has data
privacy and breach notification requirements that layer on top of HIPAA —
any state you name is worth a quick search."
Orientation summary
After receiving all answers, write a brief orientation summary and share it
before continuing:
"Got it. Here's how I'm reading your situation: [one paragraph].
I'll keep this in mind throughout the assessment. Ready to continue?"
Internal — determine conditional triggers now. Carry these forward silently:
Q2 ≥ 50 employees → background check question active in Element 3
Q5 includes HITRUST or SOC 2, OR Q6 is enterprise review → pen testing question active in Element 5
Q3 is Series B+ or Established → board reporting question active in Element 2
Q9 confirms SOC 2 Type II or HITRUST → certification override active (minimum Active Management stage)
Q10 is Yes → subcontractor BAA flag active in Element 3 and document analysis
⟳ STATE ANCHOR 1 — internal only, do not surface to user
Before starting Step 2, confirm your active state and hold it for the
entire assessment:
Conditionals active: [list each that fired: board reporting / background checks / pen testing / certification override / subcontractor flag — or "none"]
Certification override: [active — minimum Stage 2 / not active]
Extra-protected PHI (Q8): [Yes / No / Unsure]
Subcontractor PHI access (Q10): [Yes / No / Unsure]
Documents to analyze (Q7): [list types, or "none"]
Primary goal (Q6): [exact goal — shapes urgency in synthesis]
Business context (Q11): [1-sentence summary of what the org does —
use this to personalize gap narratives, roadmap framing, and state law applicability]
State law research (Q12 + Q11): [If any states were named in Q12, OR a state license
document was listed in Q7, run web searches NOW before beginning Step 2.
For each state identified, run:
"[state] health data privacy law obligations for [business type from Q11] 2026"
"[state] data protection requirements [business description from Q11]"
"[state] breach notification law healthcare [state] days"
Summarize findings in 2–3 bullets per state — key laws and obligations beyond HIPAA.
Hold these findings; they populate Section 6 of the output document.
If Q12 named no states and no state license was listed, record: "no states identified —
standard HIPAA scope; universal breach notification note still applies in output."]
These values must not drift. Reference this state when determining
which conditional questions to ask and how to weight findings.
Step 2 — Seven Elements Assessment
Present elements one at a time. For each:
Name the element and its guiding question
Ask the applicable questions conversationally
Acknowledge answers briefly before moving to the next element
Track scores internally — do not show a running score to the user
Keep the tone of a knowledgeable advisor, not an automated form.
Reframe technical questions in plain language where needed.
Scoring (internal): Yes = 1 point, No = 0, Uncertain = 0 (flag as
"unverified"). Final score = yes_count / applicable_questions × 100.
Element 1: Written Standards and Procedures
Do you have documented policies that guide compliant behavior?
Ask:
Do you have written HIPAA policies and procedures? (Enterprise trigger)
Are those policies accessible to everyone who needs them?
Are they reviewed and updated at least once a year, or whenever regulations change? (Enterprise trigger)
Element 2: Oversight by High-Level Personnel
Is there clear accountability for your compliance program?
Ask:
Do you have a designated Privacy Officer or Security Officer — or someone
formally responsible for compliance? (Enterprise trigger)
Conditional — ask only if Q3 is Series B+ or Established:
Does your board or senior leadership receive regular compliance updates?
Element 3: Due Care in Delegation
Do you screen and authorize people who access sensitive data?
Ask:
Do you have a documented process for granting and revoking access to
patient data systems? (Enterprise trigger)
Do you screen vendors and subprocessors before they handle patient data? (Enterprise trigger)
Have you executed Business Associate Agreements (BAAs) with all vendors,
subcontractors, and any offshore partners who access patient data or the
environments containing it? (Enterprise trigger)
If Q10 is Yes: After the BAA question, add naturally:
"Since you mentioned subcontractors or offshore partners have access —
does that BAA coverage extend to them specifically, or mainly to your
direct vendors?"
(Record the answer; it will inform document analysis and synthesis.)
Conditional — ask only if Q2 is 50+ employees:
Do you run background checks on employees who handle patient data?
Element 4: Effective Communication and Training
Do your people know what's expected of them?
Ask:
Have all employees who handle patient data completed HIPAA training? (Enterprise trigger)
Do you keep records of who completed training and when? (Enterprise trigger)
Do new hires get compliance training during onboarding?
Do you run annual refresher training, or update training when your policies change?
⟳ STATE ANCHOR 2 — internal only, mid-assessment check
Halfway point. Before continuing to Elements 5–7, verify:
Estimated direction: [on track for Foundation / Active Management / Proactive Defense]
Enterprise blockers so far: [list any Enterprise trigger questions answered No]
Pending conditionals still to fire: [pen testing in E5 if applicable / Active Management conditional in E7 if score is tracking ≥70%]
If the estimated direction is already clearly Foundation (<70%), note that
the Element 7 Active Management conditional will likely not fire.
Adjust Element 7 accordingly.
Element 5: Monitoring, Auditing, and Risk Assessment
Do you actively look for compliance problems before they find you?
Ask:
Have you completed a formal HIPAA risk assessment in the past 12 months? (Enterprise trigger)
Do you maintain audit logs that track who accesses patient data? (Enterprise trigger)
Can you demonstrate that audit logging capability on demand — say, if a
customer's security team asked to see it? (Enterprise trigger)
Do you review those audit logs periodically to catch unauthorized access?
Have you documented your technical safeguards — encryption, access controls,
that kind of thing? (Enterprise trigger)
Conditional — ask only if Q5 includes HITRUST or SOC 2, OR Q6 is enterprise review:
Do you conduct periodic security assessments or penetration testing? (Enterprise trigger in this context)
Element 6: Enforcement and Discipline
Do you hold people accountable when compliance rules are broken?
Ask:
Do you have documented disciplinary procedures for policy violations?
Element 7: Response and Prevention
Can you respond effectively when something goes wrong?
Ask:
Do you have a documented incident response procedure? (Enterprise trigger)
If a breach happened today, do you know who to call and what steps to take? (Enterprise trigger)
Do you have a breach notification process — both internal (telling leadership)
and external (notifying affected individuals and HHS)? (Enterprise trigger)
Have you actually tested your incident response — through a tabletop exercise
or by working through a real incident? (Enterprise trigger)
Conditional — ask only if running score suggests Active Management (≥70%):
After any past incidents, did you document what happened, notify the right
people, and update your procedures as a result?
Step 2 Scoring (internal — do not share with user yet)
Certification override: if Q9 confirmed SOC 2 Type II or HITRUST CSF →
minimum Stage 2 regardless of score
Enterprise blockers: every Enterprise trigger question answered No
⟳ STATE ANCHOR 3 — internal only, post-scoring
Lock your scores before proceeding. Do not revise these values during
document analysis — document findings will be layered in during synthesis.
Unverified answers (flagged as uncertain): [list question IDs, or "none"]
Step 3 may change the tier downward if document analysis reveals gaps.
It will never change it upward. Hold this baseline.
Step 3 — Document Analysis (run only if Q7 confirmed documents)
Ask the user to upload their documents now:
"You mentioned you have [documents]. Go ahead and upload them —
I'll work through each one."
Analyze each document type inline using the methodology below.
If multiple documents are provided, analyze in this order:
policies/procedures → BAA → other documents.
⟳ STATE ANCHOR 4 — internal only, before document analysis
Active flags that must modify your analysis of every document:
Extra-protected PHI (Q8 = Yes): Flag any document that does not
address 42 CFR Part 2, state behavioral health laws, or pediatric
data obligations as a critical gap — regardless of HIPAA coverage.
Subcontractor PHI access (Q10 = Yes): In every document, check
specifically whether subcontractor/offshore BAA chain is addressed.
Do not accept general vendor language as sufficient.
Baseline score to watch for downgrades: [carry forward score % from Anchor 3]
If findings here contradict a Yes answer, the tier may need to drop.
Enterprise blockers already identified: [carry forward list from Anchor 3]
Any document finding that confirms a blocker upgrades it to Confirmed Critical.
After analysis, cross-reference findings against Phase 2 answers and flag:
Unverified / Gap Confirmed — user said Yes, document shows a gap
Potential Asset — Formalize — user said No, document shows coverage exists
Deficient — Remediation Required — user said Yes to having a document,
but the document fails to meet requirements
For each document, assess it against HIPAA Security Rule and Privacy Rule
requirements control by control. For each control area:
Determine coverage status: Does the document address this control?
Covered: Explicit policy language with specific procedures
Partial: General intent present but lacking specific procedures
Gap: Control not addressed
Extract evidence: Pull the specific language from the document that
supports the coverage rating. Quote directly.
Rate confidence: How certain are you of the coverage assessment?
(High / Medium / Low — based on specificity of the document language)
For gaps: Assign severity (Critical / High / Medium / Low) based on
regulatory exposure. Provide 2–3 specific remediation actions.
Key HIPAA Security Rule control areas to cover:
Access controls (§164.312(a)(1))
Audit controls (§164.312(b))
Integrity controls (§164.312(c)(1))
Person or entity authentication (§164.312(d))
Transmission security (§164.312(e)(1))
Security officer designation (§164.308(a)(2))
Workforce training (§164.308(a)(5))
Contingency planning (§164.308(a)(7))
Risk analysis and management (§164.308(a)(1))
Device and media controls (§164.310(d)(1))
Business associate agreements (§164.308(b)(1))
Breach notification (§164.400–414)
If Q5 includes HITRUST, NIST 800-53, ISO 27001, or SOC 2, also note which
document sections map to the relevant framework controls. A full framework
mapping is in scope if the user requests it.
If Q8 is Yes (extra-protected PHI): Flag explicitly whether the document
addresses obligations beyond standard HIPAA — particularly 42 CFR Part 2
requirements, state behavioral health privacy laws, or pediatric data
obligations. If the document does not address these, flag as a critical gap.
3b. Business Associate Agreement — Inline BAA Review
Review the BAA against all 9 required provisions under 45 CFR 164.504(e)(2).
For each provision:
Status: Present / Deficient / Missing
Excerpt: Quote the relevant BAA language (if present)
Gap description: What is missing or insufficient
Risk level: Critical / High / Medium / Low
Remediation: Specific contract language or amendment needed
The 9 required provisions to check:
#
Provision
Common deficiency
1
Permitted uses and disclosures of PHI
Overly broad or missing use limitations
2
Prohibition on unauthorized use or disclosure
Missing or vague
3
Appropriate safeguards requirement
No reference to Security Rule safeguards
4
Reporting of breaches and security incidents
Notification window not specified or too long
5
Subcontractor requirements
Does not require written subcontractor BAAs
6
Access to PHI for individuals
Omitted or improperly delegated
7
Amendment of PHI
Omitted
8
Accounting of disclosures
Omitted
9
Termination provisions and return/destruction of PHI
Missing destruction requirement
If Q10 is Yes (subcontractors with PHI access): After reviewing the BAA,
explicitly note whether the subcontractor requirement provision (provision 5)
is sufficient to cover the specific subcontractor/offshore scenario the user
described. If not, flag as a Critical gap with specific remediation language.
3c. State license or business registration
If a state license or business registration document is uploaded:
Document findings: [list: which documents analyzed, key contradictions found]
Contradictions to resolve: [list each: question ID → self-report answer → document finding → flag label]
Revised tier (if documents changed it): [new % and label, or "unchanged"]
Risk profile amplifiers still active: [Q8 extra-protected PHI / Q10 subcontractor / no certifications]
State law flags (from Anchor 1): [restate each active flag — these must appear in Section 6 of the output; if none, note "standard HIPAA scope"]
Primary goal (Q6): [restated — this drives urgency weighting in the roadmap]
Do not begin writing synthesis output until this state is fully assembled.
The contradiction list in particular must be complete before gap prioritization begins.
Before producing output, build an internal synthesis:
Start with the Phase 2 self-reported posture
Layer in document findings — document findings override self-report
Compile the full contradiction list
Finalize the tier and stage (applying certification override if applicable)
Classify every gap using the priority matrix:
High Urgency
Low Urgency
High Severity
Priority 1 — act immediately
Priority 2 — plan in 30 days
Low Severity
Priority 3 — address in 60 days
Priority 4 — backlog
Urgency is shaped by Q6 (primary goal) — if they have an upcoming review,
urgency across all gaps increases.
Build the 30/60/90 roadmap:
Priority 1 → 30 days
Priority 2 → 60 days
Priority 3 → 90 days
Each item: specific action + element it addresses + "professional support recommended" flag if the gap is in Elements 2, 5, or 7
Map each finding type to a Rote module for the handoff section.
Only include Rote modules where an actual finding exists.
Step 5 — Output
Tell the user:
"I have everything I need. Let me put together your posture report."
Produce a polished Word document (.docx) using the docx skill.
Context — who this organization is and what they're trying to accomplish
(from orientation, written in third person for shareability)
Maturity stage and score — what it means in plain language for their
specific situation (stage, customer type, certifications)
The single most important thing they need to do next
If extra-protected PHI, subcontractor PHI access, or state law flags were
identified in orientation, include a callout box here noting the additional
risk scope.
Brief description of what this stage means for a company of their size,
stage, and customer type
Section 3: Enterprise Blockers
If none: "No enterprise blockers identified."
If any: A callout box (use a bordered/shaded box) listing each blocker with:
The gap
Why it matters to enterprise customers specifically
Whether it was confirmed by document analysis or self-reported only
Section 4: Gap Findings by Element
One subsection per element. For each:
Element name and guiding question
Table of questions with Yes/No answers and any finding labels
1–2 sentences of narrative on what this means for the organization
If document analysis found contradictions, call them out here
Section 5: Document Analysis Findings
If no documents were provided:
"No documents were provided for this assessment. All posture findings are
based on self-reported answers. Document analysis is strongly recommended
to validate these findings — particularly for Elements 1, 3, and 5, where
the gap between documented and actual compliance is most common."
If documents were provided: One subsection per document analyzed, with:
Document name and type
Key findings (coverage, gaps, contradictions with self-report)
Notable evidence citations (quoted directly)
Contradiction summary
Section 6: State Law Considerations
If Q12 named no states and no state license was provided:
"No states of operation were identified for this assessment. Note that all
states have breach notification laws with timelines that differ from HIPAA's
60-day window — verify your state-specific requirements for any future incident."
If state law flags are active: One subsection per flagged state, structured as:
State and law name (e.g., "Texas — HB 300")
Why it applies: One sentence connecting the law to the organization's
specific activities (from Q11 business description)
Primary obligations beyond HIPAA: 2–3 bullet points of the key
requirements that HIPAA compliance alone does not satisfy
Awareness gap assessment: Based on self-reported answers and any
documents analyzed, does the program appear to account for these obligations?
(Likely covered / Uncertain / Not addressed)
Recommended next step: For any flag, note that full state law analysis
is beyond this automated intake and recommend consultation with a compliance
professional familiar with the specific state obligations
Close the section with the universal breach notification note:
"All states have breach notification laws with timelines that differ from
HIPAA's 60-day window — many require notification in 30 days or less. The
most stringent applicable requirement governs. Verify your state-specific
timelines with legal counsel."
Surface findings from the web searches conducted at STATE ANCHOR 1. Do not
attempt a full state law compliance analysis beyond what the searches returned —
frame the findings and scope the consultation to professional review.
Section 7: 30/60/90 Day Roadmap
A table with columns: Action | Element | Horizon | Professional support needed?
Group by horizon (30 / 60 / 90 days / Backlog).
Write actions as specific, imperative steps — not gap descriptions.
Good: "Draft and execute BAAs with offshore development contractors."
Not: "BAA coverage gap with offshore partners."
Section 8: Next Steps with Rote
Map each major finding type to the relevant Rote module using the handoff
framing below. Only include rows where the finding exists.
Finding
Rote capability
What it means for you
Policy gaps against HIPAA controls
Gap Analysis
"Rote runs this analysis continuously against your full policy library — not just one document at a time."
BAA deficiencies or subcontractor BAA gaps
BAA Analyzer
"Rote tracks all your vendor BAAs, flags deficiencies, and alerts you when agreements need renewal or remediation."
Missing or outdated risk assessment
Gap Analysis + Reports
"Rote produces audit-ready risk assessment reports on demand, with version history."
Framework coverage gaps
Framework Management
"Rote maintains a live framework crosswalk so you know your coverage posture at any time."
Unreviewed audit logs
Compliance Chat + Reports
"Rote's compliance chat lets your team query your policy and audit documentation in natural language, grounded in your actual docs."
No audit trail for compliance decisions
Reports + Audit Trail
"Every analysis in Rote is logged, versioned, and exportable for your next review."
Team needs compliance guidance
Compliance Chat
"Rote gives your whole team cited answers from your compliance documents — without needing a compliance officer on call."
Extra-protected PHI obligations
Gap Analysis + Framework Management
"Rote tracks additional regulatory obligations alongside HIPAA controls so nothing falls through the cracks."
Untested incident response
Reports + Audit Trail
"Rote keeps a versioned record of every analysis and incident response action — so your next tabletop has documentation to work from."
Close with the CTA appropriate to maturity stage:
Foundation: "Your results suggest that a structured program buildout is
the right first step before activating Rote. Book a consultation
to build a compliance roadmap with a fractional CCO. Rote will be most
valuable once the foundation is in place."
Active Management: "Your program is well-structured to benefit from
Rote. The platform will automate the analysis work you're currently doing
manually and give your team continuous visibility into your posture.
Learn more about Rote or join the waitlist."
Proactive Defense: "Rote Enterprise is designed for organizations at
your maturity level — continuous compliance monitoring at scale, with
team collaboration, API access, and audit-ready reporting built in.
Explore Rote Enterprise."
Section 9: Email Summary
A short paragraph the user can paste directly into an email to their team,
a consultant, or a Rote account setup. Plain prose, no jargon. Covers:
maturity stage, top 2–3 findings, and what they're doing about it.
After delivering the document, say:
"Your posture report is ready. [Link to file]
The most important thing to act on right now is [top Priority 1 item in
one plain sentence]. If you'd like help working through the roadmap —
or if you want to talk through what a consultation engagement would look
like — book a time here."
Execution Notes
Never present all questions at once. The conversational flow matters —
it signals competence and keeps the user engaged through a 15-minute process.
Reframe technical questions naturally when needed. "We maintain audit logs
that track access to PHI" can be asked as "Do you keep audit logs that
record who accesses patient data, and can you pull those logs if asked?"
If a user is uncertain on a question, offer a brief explanation, then let
them answer. Do not lead them toward a Yes or No.
If the user has third-party certifications, acknowledge this positively
after orientation and explain how the assessment will complement their
existing validated controls rather than duplicate the certification work.
The Word document should be polished enough to share externally.
Use professional formatting: cover page, section headings, callout boxes
for blockers and risk flags, a clean roadmap table.
Do not include the internal scoring breakdown or conditional trigger logic
in the output document. Those are execution aids, not user-facing content.
