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Assessment — Compliance Gap Analysis

A template for identifying gaps between your current control implementation and the requirements of a target compliance framework. This assessment works with any framework — FedRAMP, SOC 2, HIPAA, PCI-DSS, CMMC, NIST CSF, or others — and maps identified gaps to CSA-in-a-Box capabilities that can accelerate remediation.


Framework selection guide

Start by identifying which compliance framework(s) apply to your organization. The table below maps common industries and scenarios to recommended frameworks.

Industry / Scenario Primary Framework Secondary Frameworks CSA-in-a-Box Coverage
Federal civilian agencies FedRAMP Moderate (NIST 800-53 Rev 5) FISMA, OMB M-22-09 (Zero Trust), CISA BODs FedRAMP Moderate, NIST 800-53 Rev 5
DoD / defense contractors CMMC 2.0 Level 2 NIST 800-171, DFARS 252.204-7012, ITAR CMMC 2.0 L2
DoD classified (CUI/NSS) FedRAMP High + DoD SRG IL4/IL5 NIST 800-53 High baseline, CNSSI 1253 NIST 800-53 Rev 5, DoD IL4/IL5
Healthcare HIPAA Security Rule HITRUST CSF, NIST CSF HIPAA Security Rule
Financial services SOC 2 Type II PCI-DSS v4, GLBA, NYDFS 23 NYCRR 500 SOC 2 Type II, PCI-DSS v4
Payment processing PCI-DSS v4.0 SOC 2 Type II PCI-DSS v4
State / local government StateRAMP or FedRAMP Moderate CJIS (law enforcement), IRS 1075 (tax data) FedRAMP Moderate
EU data processing GDPR SOC 2, ISO 27001 GDPR & EU Data Boundary
Enterprise SaaS SOC 2 Type II ISO 27001, NIST CSF 2.0 SOC 2 Type II
Multi-framework NIST 800-53 Rev 5 (superset) Map to specific frameworks as needed NIST 800-53 Rev 5

Start with NIST 800-53 for multi-framework needs

If you need to satisfy multiple frameworks, start with NIST 800-53 Rev 5 as your control baseline. Most other frameworks (FedRAMP, CMMC, HIPAA, SOC 2) map to NIST 800-53 controls, so a single gap analysis against 800-53 can inform remediation across all of them.


Gap analysis process

Follow these five steps to complete the analysis:

flowchart LR
    A["1. Select Target<br/>Framework"] --> B["2. Map Current<br/>Controls"]
    B --> C["3. Identify<br/>Gaps"]
    C --> D["4. Prioritize<br/>by Risk"]
    D --> E["5. Create<br/>Remediation Plan"]

    style A fill:#e3f2fd
    style B fill:#e3f2fd
    style C fill:#fff3e0
    style D fill:#fff3e0
    style E fill:#c8e6c9

Step 1 — Select target framework

  • Identify the compliance framework(s) required for your deployment
  • Obtain the official control catalog (e.g., NIST 800-53 Rev 5 control catalog, PCI-DSS v4 requirements)
  • Determine the applicable baseline or scope (e.g., FedRAMP Moderate vs. High, CMMC Level 1 vs. Level 2)
  • Identify any agency-specific or customer-specific overlays (additional requirements beyond the base framework)

Step 2 — Map current controls

For each control in the target framework, document your current implementation state:

  • Inventory existing policies, procedures, and technical controls
  • Determine which controls are inherited from the cloud provider (Azure shared responsibility)
  • Identify controls implemented by CSA-in-a-Box Bicep modules, policies, and configurations
  • Document controls that your organization implements through operational processes
  • Classify each control using the status codes defined below

Control status codes (aligned with CSA-in-a-Box compliance manifests):

Status Definition
IMPLEMENTED Control is fully satisfied. Evidence exists (code, configuration, documentation, logs).
PARTIALLY_IMPLEMENTED Some evidence exists but gaps remain. Control is not fully satisfied.
PLANNED Control is not yet implemented. A plan and timeline exist for remediation.
NOT_APPLICABLE Control does not apply to your system's scope, architecture, or classification. Justification required.
INHERITED Control is satisfied by an upstream provider (Azure, Microsoft 365, etc.) under the shared responsibility model.
NOT_ASSESSED Control has not yet been evaluated. Starting state for new gap analyses.

Step 3 — Identify gaps

A gap exists when a control is in any state other than IMPLEMENTED, NOT_APPLICABLE, or INHERITED:

  • Flag all PARTIALLY_IMPLEMENTED controls — document what is missing
  • Flag all PLANNED controls — document the timeline and effort
  • Flag all NOT_ASSESSED controls — schedule evaluation
  • For INHERITED controls, verify the inheritance claim against the CSP's authorization documentation
  • Document compensating controls where full implementation is not feasible

Step 4 — Prioritize gaps by risk

Score each gap on impact and likelihood to determine remediation priority:

  • Assess the impact of non-compliance for each gap (data exposure, regulatory penalty, operational disruption)
  • Assess the likelihood that the gap could be exploited or result in an audit finding
  • Assign priority (Critical, High, Medium, Low) using the risk matrix below
  • Group related gaps for efficient remediation

Priority matrix:

High Likelihood Medium Likelihood Low Likelihood
High Impact Critical — Remediate immediately High — Remediate within 30 days Medium — Remediate within 90 days
Medium Impact High — Remediate within 30 days Medium — Remediate within 90 days Low — Remediate within 180 days
Low Impact Medium — Remediate within 90 days Low — Remediate within 180 days Low — Accept or remediate opportunistically

Step 5 — Create remediation plan

For each gap, document the remediation approach:

  • Define the remediation action (implement control, configure service, write policy, deploy module)
  • Identify the responsible owner
  • Set a target completion date based on priority
  • Estimate effort (hours/days) and resources needed
  • Identify CSA-in-a-Box resources that address the gap (see resource mapping below)
  • Define success criteria (how will you know the control is satisfied?)
  • Plan evidence collection for future audits

Control mapping template

Use the following table format to document your gap analysis. Create one row per control in your target framework.

Control ID Control Name Current Status Gap Description Priority Remediation Action Owner Target Date CSA-in-a-Box Resource
AC-2 Account Management PARTIAL No automated deprovisioning High Implement Entra ID lifecycle workflows Security Team [Date] Identity & Secrets Flow
AC-6 Least Privilege IMPLEMENTED Bicep RBAC modules
AU-6 Audit Record Review PLANNED No automated review Medium Deploy Sentinel workbooks SOC Team [Date] Monitoring Best Practices

Common gaps by framework

The following sections identify the most frequently encountered gaps for each major framework. Use these as a starting point — not a substitute for a complete control-by-control analysis.

FedRAMP Moderate — Top gaps

Gap Area Typical Finding CSA-in-a-Box Remediation
Continuous monitoring (CA-7) No automated vulnerability scanning or configuration monitoring Deploy Defender for Cloud with continuous assessment; configure Azure Policy compliance dashboards
Contingency plan testing (CP-4) DR plan exists but has never been tested Use the DR Drill Runbook to conduct tabletop and functional tests
Configuration management (CM-2, CM-6) No baseline configurations documented or enforced Bicep modules serve as the configuration baseline; Azure Policy enforces configuration drift detection
Incident response (IR-4, IR-5) No documented incident response procedures or post-incident analysis process Deploy the Security Incident Runbook; integrate with Defender for Cloud alerts
Audit record review (AU-6) Logs collected but not reviewed; no automated alerting for security events Configure Log Analytics alert rules; deploy Sentinel for automated analysis; see Monitoring Best Practices

For the complete FedRAMP control crosswalk, see FedRAMP Moderate.

SOC 2 Type II — Top gaps

Gap Area Typical Finding CSA-in-a-Box Remediation
Change management (CC8.1) Changes deployed without formal approval or documentation GitHub branch protection, PR reviews, and CI/CD pipelines enforce change management; see IaC & CI/CD Best Practices
Risk assessment (CC3.1-CC3.4) No formal risk assessment process or documentation Use the Migration Readiness Assessment risk matrix as a starting template; conduct annual risk assessments
Logical access reviews (CC6.1-CC6.3) Access granted but not reviewed periodically Entra ID Access Reviews, PIM for just-in-time access; see Identity & Secrets Flow
Monitoring and detection (CC7.2-CC7.3) No centralized monitoring or anomaly detection Defender for Cloud, Log Analytics, and Sentinel provide detection capabilities; see Monitoring Best Practices
Vendor management (CC9.2) No formal process for assessing third-party risk Document vendor risk assessment process; review Azure's SOC 2 report for inherited controls

For the complete SOC 2 TSC crosswalk, see SOC 2 Type II.

HIPAA Security Rule — Top gaps

Gap Area Typical Finding CSA-in-a-Box Remediation
Risk analysis (§164.308(a)(1)) No documented risk analysis covering ePHI Conduct risk analysis using NIST 800-30 methodology; document in POA&M format
Audit controls (§164.312(b)) Insufficient logging of ePHI access Enable diagnostic settings on all data stores; configure audit logging for database access; see Log Schema
Encryption at rest (§164.312(a)(2)(iv)) Some data stores lack encryption or use platform-managed keys only Bicep modules deploy CMK encryption via Key Vault; see Security Best Practices
Business associate agreements (§164.308(b)) BAAs not in place with all vendors processing ePHI Review Azure BAA (available via Microsoft Trust Portal); ensure BAAs with all subprocessors
Contingency planning (§164.308(a)(7)) No backup or disaster recovery plan for ePHI systems Deploy geo-redundant storage; use DR Planning guide for recovery procedures

For the complete HIPAA crosswalk, see HIPAA Security Rule.

PCI-DSS v4.0 — Top gaps

Gap Area Typical Finding CSA-in-a-Box Remediation
Network segmentation (Req 1) Cardholder data environment not segmented from other networks Hub-spoke topology with dedicated subnets; Azure Firewall Premium rules; Private Endpoints; see Hub-Spoke Topology
Encryption in transit (Req 4) TLS 1.0/1.1 still enabled on some services Bicep modules enforce TLS 1.2+ minimum; Azure Policy denies non-compliant configurations
Access control (Req 7-8) Excessive access to cardholder data; no MFA for administrative access Entra ID with PIM, Conditional Access with MFA; RBAC scoped to minimum necessary
Logging and monitoring (Req 10) Audit trail does not cover all cardholder data access Diagnostic settings on all data stores; centralized Log Analytics with 12-month retention
Vulnerability management (Req 6, 11) No regular vulnerability scanning or penetration testing Defender for Cloud vulnerability assessment; see Supply Chain for dependency scanning

For the complete PCI-DSS crosswalk, see PCI-DSS v4.

CMMC 2.0 Level 2 — Top gaps

Gap Area Typical Finding CSA-in-a-Box Remediation
CUI identification (3.1.3, 3.8.1-3.8.5) CUI not identified, marked, or handled per NIST 800-171 requirements Purview sensitivity labels for CUI classification; data handling policies; see Data Governance
Multi-factor authentication (3.5.3) MFA not enforced for all CUI access Entra ID Conditional Access with phishing-resistant MFA; see Identity & Secrets Flow
Security awareness training (3.2.1-3.2.3) No role-based security training program Customer-implement; platform provides Developer Pathways for technical training
Audit log protection (3.3.8-3.3.9) Audit logs not protected from unauthorized modification Immutable storage for Log Analytics; RBAC restricts log deletion; see Environment Protection
System security plan (3.12.4) No SSP documenting security controls Use CSA-in-a-Box compliance manifests as SSP evidence source; see CMMC 2.0 L2

For the complete CMMC practice mapping, see CMMC 2.0 Level 2.


CSA-in-a-Box control mapping

The following table maps CSA-in-a-Box capabilities to common compliance control areas. Use this to identify which platform features address your identified gaps.

Control Area CSA-in-a-Box Capability Implementation Evidence
Identity & access management Entra ID, PIM, Conditional Access, RBAC, managed identities Bicep RBAC modules, ADR 0014, Identity & Secrets Flow
Network security Hub-spoke topology, Azure Firewall Premium, Private Endpoints, NSGs, Private DNS Bicep network modules, Hub-Spoke Topology
Encryption at rest CMK via Key Vault, Azure Storage encryption, database TDE Bicep Key Vault modules, Security Best Practices
Encryption in transit TLS 1.2+ enforced, Private Endpoints eliminate public traffic Azure Policy assignments, Bicep service configurations
Logging & monitoring Log Analytics, Diagnostic Settings, Activity Log, Defender for Cloud Log Schema, Monitoring Best Practices
Vulnerability management Defender for Cloud, Defender for SQL, dependency scanning, SBOM Supply Chain, CI/CD pipeline scanning
Configuration management Bicep IaC, Azure Policy, GitHub branch protection IaC & CI/CD Best Practices
Disaster recovery Geo-redundant storage, multi-region Bicep modules, documented DR procedures DR Planning, DR Drill Runbook, Multi-Region
Data governance Purview classification, sensitivity labels, data lineage, access policies Data Cataloging, Data Lineage
Incident response Defender for Cloud alerts, documented runbooks, escalation procedures Security Incident Runbook
Supply chain Pinned dependencies, SBOM generation, signed artifacts, Dependabot, Trivy Supply Chain
Data quality Automated quality checks, freshness monitoring, schema enforcement Data Quality, Data Engineering Best Practices

Remediation priority matrix

After completing the gap analysis, summarize your remediation priorities:

Priority Count Target Resolution Actions
Critical ___ Immediate (within 2 weeks) ___
High ___ Within 30 days ___
Medium ___ Within 90 days ___
Low ___ Within 180 days ___
Total gaps ___

Remediation tracking

For ongoing tracking, maintain a remediation log:

# Control ID Gap Description Remediation Action Owner Target Date Actual Date Status Evidence
1
2
3

Continuous compliance

Gap analysis is not a one-time activity. Establish ongoing compliance monitoring:

  • Quarterly gap review — Reassess gaps and update remediation status
  • Azure Policy compliance — Monitor Azure Policy compliance dashboard for configuration drift
  • Defender for Cloud secure score — Track secure score trend as a proxy for security posture
  • Automated evidence collection — Configure diagnostic settings and Log Analytics to generate audit evidence continuously
  • Annual full assessment — Conduct a complete gap analysis annually or when the target framework updates
  • Incident-driven review — Reassess relevant controls after security incidents

OSCAL for automation

As FedRAMP moves toward OSCAL-formatted security packages, consider generating machine-readable control documentation from your CSA-in-a-Box deployment. This is on the CSA-in-a-Box Phase 2 roadmap. See Federal Cloud Adoption Trends for the latest on FedRAMP automation.



Last updated: 2026-04-30 Review cadence: Annual (or when target framework releases updates) Owner: CSA-in-a-Box platform team