Clumio

Policies and Procedures (11.6)

Vulnerability Scanning (11.2)

Change management policies are established that include procedures for tracking, testing, approving, and communicating changes. Policies are reviewed annually.

All system change requests are formally documented, including a description of the change, justification, and affected systems or components.

A formal risk management process is established to evaluate risks based on identified threats and specified tolerances. This process includes defining risk assessment methodologies, risk categories, and evaluation criteria.

Risk assessments are performed at least annually during security committee management meetings and include evaluations of the following: -Organizational structure, capability, capacity, reporting lines, authorities, and responsibilities. -Environmental, regulatory, and technological changes that have occurred. -The need for additional tools and resources to achieve business objectives. -Threats and vulnerabilities affecting the achievement of commitments to clients.

Results of the risk assessment, including identified risks and recommended actions, are communicated to the respective owners to ensure accountability for addressing risks.

Identified risks and associated action items are documented and tracked through an ongoing risk register to monitor progress and ensure timely resolution.

DE.CM-01: Networks and network services are monitored to find potentially adverse events

DE.CM-06: External service provider activities and services are monitored to find potentially adverse events

8.12 Data leakage prevention - Data leakage prevention measures shall be applied to systems, networks and any other devices that process, store, or transmit sensitive information.

8.15 Logging - Logs that record activities, exceptions, faults, and other relevant events shall be produced, stored, protected, and analyzed.

Access Control 7 P & P - Is there a policy to control the access of staff, vendors, and 3rd party personnel to critical equipment (network devices, servers, etc.)?

Passwords P & P - Is there a password policy to ensure that minimum HIPAA password compliance is met?

Access Control 2 P & P - Are there both policies and procedures to ensure that idle computing devices enable lock screen after 10 minutes of non-use?

Security event reporting - Are there both policies and procedures that define a security event and provide instruction for communicating the event to appropriate personnel?

Protections 4 P & P - Are there processes in place to ensure that members of the public and staff without authorization cannot see ePHI (on computer screens, printers, desktops, etc)?

Access Control 3 P & P - Are there both policies and procedures to ensure that user accounts are unique, not shared amongst users?

Protections 3 P & P - Are there both Policies and Procedures to ensure that confidential, private, and ePHI data is encrypted throughout the organization's domain?

Protections 1 P & P - Are there both policies and procedures that ensure that systems are protected with anti-virus/anti-malware programs?

IT Procedure Alignment Process - Does the org have a process by which IT management develops, implements, reviews, and updates digital security procedures to align to written policy?

Access Control 1 P & P - Are there both an Access Control policy and procedure to manage the authenticated and authorized access of people and systems to internal org resources?

Sanctions - Does the organization have sanctioning in its policies to help enforce security procedures?

Access Control 5 P & P - Are there both policies and procedures to ensure that users are permitted only those permissions necessary to perform their role (Principle of Least Privilege)?

Access Control 6 P & P - Are there both policies and procedures to ensure that idle account access to EHR portals and systems lock-out (require credentials to log back in)?

Access Control 4 P & P - Are there both policies and procedures to ensure that administrative rights are not allocated inappropriately?

Protections 2 P & P - Are there both policies and procedures that ensure that systems receive regular (at least monthly) updates and patches to minimize vulnerabilities?

Periodically assess the risk to organizational operations, organizational assets, and individuals, resulting from the operation of organizational systems and the associated processing, storage, or transmission of CUI.