Audit Reveals Hospital System Failed to Attest to Cybersecurity Controls Ahead of Regulatory Change

The Challenge

In late 2024, Maple Ridge Health Network (MRHN), a large regional healthcare provider operating across Ontario and Manitoba, found itself under the scrutiny of federal and provincial regulators. The issue was not a data breach, ransomware attack, or insider threat. It was something far more procedural, yet deeply consequential: a failure to attest to its cybersecurity controls before a newly mandated regulatory deadline.

The requirement had been clearly communicated months in advance. Under Canada’s evolving privacy and security oversight frameworks, particularly those guided by PIPEDA and provincial health privacy laws, healthcare organizations were now required to formally attest that their cybersecurity controls were implemented, tested, and actively maintained. For regulators, this attestation was more than paperwork—it was a demonstration of due diligence and ethical accountability in safeguarding patient data.

At MRHN, however, poor coordination and unclear responsibility created a serious gap. The compliance department, already juggling accreditation renewals and privacy impact assessments, believed the IT Security team was managing the attestation. Meanwhile, IT assumed Legal and Compliance were handling the submission. As weeks passed without clarification, the deadline quietly expired.

An internal audit soon revealed a troubling pattern. Documentation showed that several cybersecurity controls, including privileged access reviews, data retention audits, and vendor security assessments, had not been validated in over a year. The hospital’s cybersecurity posture was still operationally sound, but without updated evidence, it could not be proven compliant. In the language of auditors, “not attested” effectively meant “not compliant.”

When the issue surfaced during a provincial compliance review, MRHN was cited for failure to demonstrate adequate governance and control attestation under the new federal standards. The citation triggered mandatory reporting to oversight bodies, a temporary hold on certain federal funding streams, and an external audit of its privacy and cybersecurity governance.

The reputational impact was swift. Local media raised questions about the hospital’s security readiness, while data-sharing partners delayed renewals pending proof of remediation. Internally, leaked memos referencing “cyber compliance deficiencies” heightened anxiety among staff and patients.

The irony was clear: MRHN’s security program had not failed technically, but its governance and documentation had. Under Canadian law, the ability to demonstrate due diligence is as important as the act of being diligent. The missed attestation became a clear example of how compliance oversights can resemble security failures, with equally damaging consequences.

This incident reinforced a crucial lesson: in healthcare, strong cybersecurity controls are not enough—they must also be documented, verified, and attested in a timely and transparent manner.

Our Solution

Audit & Attestation Recovery Program (AARP) aligned to PIPEDA, provincial health privacy obligations, and recognized control frameworks (ISO/IEC 27001, NIST CSF, CIS).

Stabilize Compliance: Establish a RACI for ownership (Board/CIO/Chief Compliance Officer), issue a documentation preservation notice, and stand up a cross-functional attestation “war room.”

Evidence & Gap Sweep: Rapid collection and testing of control evidence (IAM/privileged reviews, patch & vulnerability cadence, IR exercises, logging/monitoring, encryption, backup/DR). Map evidence to the required attestation schema.

Risk Assessment (Governance-Focused): Point-in-time assessment of control assurance gaps affecting PHI confidentiality, integrity, and availability; quantify likelihood/impact; determine treatment vs. acceptance with executive sign-off.

Attestation Dossier & Governance Uplift: Compile a regulator-ready dossier, formalize a calendarized control testing plan, and deploy a Board cyber-compliance dashboard (KPIs/KRIs: % controls evidenced in last 90 days, open audit findings age, third-party assurance coverage).

Regulatory & Partner Communications: Prepare consistent statements and status updates for oversight bodies, funders, and data-sharing partners; align with Legal/Privacy.

The Value

Regulatory Assurance: Clear, defensible attestation mapped to PIPEDA safeguards and provincial requirements; reduction in non-compliance exposure estimated by 60–80% (based on closure of evidence gaps and validation cadence).

Audit Readiness: Increase in “controls evidenced within 90 days” from baseline to , improving outcomes in external audits and accreditation reviews.

Operational Efficiency: Consolidated evidence management reduces time to compile attestations from typical multi-week cycles to <10 business days for subsequent cycles.

Third-Party Confidence: Documented vendor assurance coverage improved to of critical providers, supporting renewals of data-sharing agreements and insurer questionnaires.

Board Visibility: KPI/KRI dashboard provides quarterly governance insights, enabling earlier intervention and more accurate disclosures.

Implementation Roadmap

Week 0–1 | Mobilize & Preserve

Appoint executive sponsor; confirm RACI; legal hold on security records; inventory all in-scope systems, vendors, and prior audits.

Week 1–3 | Evidence Collection & Control Testing

Run accelerated evidence sweep across IAM, vulnerability/patching, IR, logging, encryption, and backup/DR; perform spot tests and sample-based validations; document exceptions.

Week 3–4 | Risk Assessment & Prioritization

Conduct governance-focused risk assessment; rate likelihood/impact to PHI and clinical resilience; define remediation owners, timelines, and acceptance criteria.

Week 4–6 | Attestation Dossier Assembly

Compile regulator-ready attestation package (policies, procedures, test results, SOC reports, vendor assurances); map to PIPEDA principles and applicable provincial rules.

Week 6–8 | Governance Uplift & Reporting

Implement calendarized control testing, evidence refresh cycles, and the Board dashboard; formalize variance handling and exception approvals.

Ongoing (Quarterly/Annual) | Sustain & Improve
Quarterly evidence refresh and tabletop exercises; annual independent review; vendor assurance recertification; continuous KPI/KRI monitoring and Board reporting.

Info Sheet

Necessary Action Type & Steps to Be Taken:

• Establish RACI model for cybersecurity attestation accountability.
  – Conduct full evidence sweep of cybersecurity controls including IAM, patch management, and vendor reviews.
  – Perform governance-focused risk assessment to identify and prioritize control assurance gaps.
  – Compile and submit attestation dossier including policies, procedures, and control testing evidence.
  – Develop quarterly control testing plan and board-level compliance dashboard.
  – Align external communications with regulators and partners on compliance remediation.

Industry Sector: Healthcare (Hospital and Health Network)

Applicable Legislation: PIPEDA, PHIPA (Ontario), PHIA (Manitoba)

Third Parties: Managed Service Providers, Cloud Hosting Vendors, EHR Providers, External Audit Firms, Cyber Insurance Providers, Provincial Health Authorities, Legal Counsel