Fluid Client Assistance

Information Security Policy

by Erroll Marchais Updated on

Provided By:

Fluid Networks

80 Wood Road

Suite 308

Camarillo, CA 93010


For questions, please contact us at 805.585.6350


Developed By:

Fluid Networks

Health Information Technology Research Center (HITRC)


Last Revision Date

4-7-2022 Rev. 3

Document Owner

Erroll Marchais, Security/Privacy Officer
Fluid Networks

Policy and Procedure


PP #: IS-1.0

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology



This policy defines the technical controls and security configurations users and Information Technology (IT) administrators are required to implement in order to ensure the integrity and availability of the data environment at Fluid Networks, Inc. hereinafter, referred to as FN. It serves as a central policy document with which all employees and contractors must be familiar, and defines actions and prohibitions that all users must follow. The policy provides FN IT managers and technicians with policies and guidelines concerning the acceptable use of FN and Client technology equipment, e-mail, Internet connections, voice-mail, facsimile, future technology resources and information processing.

The policy requirements and restrictions defined in this document shall apply to all FN network infrastructures, databases, external media, encryption, hardcopy reports, films, slides, models, wireless, telecommunication, conversations, and any other methods used to convey knowledge and ideas across all hardware, software, and data transmission mechanisms. This policy must be adhered to by all FN employees or temporary workers at all locations and by contractors working with FN as subcontractors.


This policy document defines common security requirements for all FN personnel and systems that create, maintain, store, access, process or transmit information. This policy also applies to information resources owned by others, such as contractors of FN, entities in the private sector, in cases where FN has a legal, contractual or fiduciary duty to protect said resources while in FN influence. In the event of a conflict, the more restrictive measures apply. This policy covers FN network systems which is comprised of various hardware, software, communication equipment and other devices designed to assist FN in the creation, receipt, storage, processing, management and transmission of information. This definition includes equipment connected to any FN domain or VLAN, either hardwired or wirelessly, and includes all stand-alone equipment that is deployed by FN at its office locations or at remote locales.

Acronyms / Definitions

Common terms and acronyms which may be used throughout this document.

FN-Fluid Networks

FN Anti-Virus – AVG

FN Address – 80 N. Wood Rd. Camarillo CA. 93010

Client Person or entity who has hired FN to perform IT services

BA – Compulink Business Systems

BDR - Backup and Disaster Recovery system

CEO – The Chief Executive Officer is responsible for the overall privacy and security practices of the company.

CIO – The Chief Information Officer

CMO – The Chief Medical Officer.

CO – The Confidentiality Officer is responsible for annual security training of all staff on confidentiality issues.

CPO – The Chief Privacy Officer is responsible for HIPAA privacy compliance issues.

CST – Confidentiality and Security Team

DoD – Department of Defense

Encryption – The process of transforming information, using an algorithm, to make it unreadable to anyone other than those who have a specific ‘need to know.’

ePHI - Electronic Patient Health Information.  
*** Anywhere this document mentions ePHI, Patient Information, Patient Records, or Data, the term "Customer Data" can also be substituted in order that this Information Policy Document is applicable to all data owned by FN Clients whether at rest or in transit.

External Media –i.e. CD-ROMs, DVDs, floppy disks, flash drives, USB keys, thumb drives, tapes

FAT – File Allocation Table - The FAT file system is relatively uncomplicated and an ideal format for floppy disks and solid-state memory cards. The most common implementations have a serious drawback in that when files are deleted and new files written to the media, their fragments tend to become scattered over the entire media, making reading and writing a slow process.

Firewall – a dedicated piece of hardware or software running on a computer which allows or denies traffic passing through it, based on a set of rules.

FTP – File Transfer Protocol

HIPAA - Health Insurance Portability and Accountability Act

ISO – Information Security Officer (also called Privacy Officer)

IT - Information Technology

LAN – Local Area Network – a computer network that covers a small geographic area, i.e. a group of buildings, an office.

NTFS – New Technology File Systems NTFS has improved support for metadata and the use of advanced data structures to improve performance, reliability, and disk space utilization plus additional extensions such as security access control lists and file system journaling. The exact specification is a trade secret of Microsoft.

SOW - Statement of Work - An agreement between two or more parties that details the working relationship between the parties and lists a body of work to be completed.

User - Any person authorized to access an information resource.

Privileged Users – system administrators and others specifically identified and authorized by FN management.

Users with edit/update capabilities – individuals who are permitted, based on job assignment, to add, delete, or change records in a database.

Users with inquiry (read only) capabilities – individuals who are prevented, based on job assignment, from adding, deleting, or changing records in a database. Their system access is limited to reading information only.

VLAN – Virtual Local Area Network – A logical network, typically created within a network device, usually used to segment network traffic for administrative, performance and/or security purposes.

VPN – Virtual Private Network – Provides a secure passage through the public Internet.

WAN – Wide Area Network – A computer network that enables communication across a broad area, i.e. regional, national.

Virus - a software program capable of reproducing itself and usually capable of causing great harm to files or other programs on the computer it attacks. A true virus cannot spread to another computer without human assistance.

Applicable Statutes / Regulations

The following is a list of the various agencies/organizations whose laws, mandates, and regulations were incorporated into the various policy statements included in this document.


Each of the policies defined in this document is applicable to the task being performed – not just to specific departments or job titles.

Privacy Officer

FN has established a Privacy Officer as required by HIPAA. This Privacy Officer (also referred to as the Information Security Officer or ISO) will oversee all ongoing activities related to the development, implementation, and maintenance of FN privacy policies in accordance with applicable federal and state laws.

Confidentiality / Security Team (CST)

FN has established a Confidentiality / Security Team made up of key personnel whose responsibility it is to identify areas of concern within FN and act as the first line of defense in enhancing the appropriate security posture.

All members identified within this policy are assigned to their positions by the CEO. The term of each member assigned is at the discretion of the CEO, but generally it is expected that the term will be one year. Members for each year will be assigned at the first meeting of the Quality Council in a new calendar year. This committee will consist of the positions within FN most responsible for the overall security policy planning of the organization- the CEO, PO, CMO, ISO, and the CIO (where applicable). The current members of the CST are:

  • Executive Vice President - Erroll Marchais
  • Vice President of Information Technology – Eric Fox
  • Internal Systems Administration – Damian Stalls

The CST will meet quarterly to discuss security issues and to review concerns that arose during the quarter. The CST will identify areas that should be addressed during annual training and review/update security policies as necessary.

The CST will address security issues as they arise and recommend and approve immediate security actions to be undertaken. It is the responsibility of the CST to identify areas of concern within FN and act as the first line of defense in enhancing the security posture of FN.

The CST is responsible for maintaining a log of security concerns or confidentiality issues. This log must be maintained on a routine basis, and must include the dates of an event, the actions taken to address the event, and recommendations for personnel actions, if appropriate. This log will be reviewed during the quarterly meetings.

The Privacy Officer (PO) or other assigned personnel is responsible for maintaining a log of security enhancements and features that have been implemented to further protect all sensitive information and assets held by FN. This log will also be reviewed during the quarterly meetings.

Policy and Procedure


PP #: IS-1.1

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS002, TVS003)

Employee Responsibilities

Employee Requirements

The first line of defense in data security is the individual FN user. FN users are responsible for the security of all data which may come to them in whatever format. FN is responsible for maintaining ongoing training programs to inform all users of these requirements.

Wear Identifying Badge so that it may be easily viewed by others - In order to help maintain building security, all employees should prominently display their employee identification badge. Contractors who may be in FN facilities are provided with a signed for security badge. Other people who may be within FN facilities should be wearing visitor badges and should be chaperoned.

Challenge Unrecognized Personnel - It is the responsibility of all FN personnel to take positive action to provide physical security. If you see an unrecognized person in a restricted FN office location, you should challenge them as to their right to be there. All visitors to FN offices must sign in at the front desk. In addition, all visitors, excluding patients, must wear a visitor/contractor badge. All other personnel must be employees of FN. Any challenged person who does not respond appropriately should be immediately reported to supervisory staff.

Secure Laptop with a Cable Lock FN laptops that contain ePHI will have a Cable Lock. This is unnecessary if FN laptop contains no ePHI.

Unattended Computers - Unattended computers should be locked by the user when leaving the work area. This feature is discussed with all employees during yearly security training. FN policy states that all computers will have the automatic screen lock function set to automatically activate upon fifteen minutes of inactivity. Employees are not allowed to take any action which would override this setting.

Home Use of FN Corporate Assets - Only computer hardware and software owned or approved by FN is permitted to be connected to or installed on FN equipment. Only software that has been approved for corporate use by FN may be installed on FN equipment. Personal computers supplied by FN are to be used solely for business purposes. All employees and contractors must read and understand the list of prohibited activities that are outlined below. Modifications or configuration changes are not permitted on computers supplied by FN for home use.

Retention of Ownership - All software programs and documentation generated or provided by employees, consultants, or contractors for the benefit of FN are the property of FN unless covered by a contractual agreement. Nothing contained herein applies to software purchased by FN employees at their own expense.

Prohibited Activities

Personnel are prohibited from the following activities. The list is not inclusive. Other prohibited activities are referenced elsewhere in this document.

Crashing an information system. Deliberately crashing an information system is strictly prohibited. Users may not realize that they caused a system crash, but if it is shown that the crash occurred as a result of user action, a repetition of the action by that user may be viewed as a deliberate act.

Attempting to break into an information resource or to bypass a security feature. This includes running password-cracking programs or sniffer programs, and attempting to circumvent file or other resource permissions.

Introducing, or attempting to introduce, computer viruses, Trojan horses, peer-to-peer (“P2P”) or other malicious code into an information system.

Exception: Authorized information system support personnel, or others authorized by FN Privacy Officer, may test the resiliency of a system. Such personnel may test for susceptibility to hardware or software failure, security against hacker attacks, and system infection.

Browsing. The willful, unauthorized access or inspection of confidential or sensitive information to which you have not been approved on a "need to know" basis is prohibited. FN has access to patient level health information which is protected by HIPAA regulations which stipulate a "need to know" before approval is granted to view the information. The purposeful attempt to look at or access information to which you have not been granted access by the appropriate approval procedure is strictly prohibited.

Personal or Unauthorized Software. Use of personal software is prohibited. All software installed on FN computers must be approved by FN.

Software Use. Violating or attempting to violate the terms of use or license agreement of any software product used by FN is strictly prohibited.

System Use. Engaging in any activity for any purpose that is illegal or contrary to the policies, procedures or business interests of FN is strictly prohibited.

2.3 Electronic Communication, E-mail, Internet Usage

As a productivity enhancement tool, FN encourages the business use of electronic communications. However, all electronic communication systems and all messages generated on or handled by FN owned equipment are considered the property of FN – not the property of individual users. Consequently, this policy applies to all FN employees and contractors, and covers all electronic communications including, but not limited to, telephones, e-mail, voice mail, instant messaging, Internet, fax, personal computers, and servers.

FN provided resources, such as individual computer workstations or laptops, mobile devices, computer systems, networks, e-mail, and Internet software and services are intended for business purposes. However, incidental personal use is permissible as long as:

  1. it does not consume more than a trivial amount of employee time or resources,
  2. it does not interfere with staff productivity,
  3. it does not preempt any business activity,
  4. it does not violate any of the following:
  5. Copyright violations – This includes the act of pirating software, music, books and/or videos or the use of pirated software, music, books and/or videos and the illegal duplication and/or distribution of information and other intellectual property that is under copyright.
  6. Illegal activities – Use of FN information resources for or in support of illegal purposes as defined by federal, state or local law is strictly prohibited.
  7. Commercial use – Use of FN information resources for personal or commercial profit is strictly prohibited.
  8. Political Activities – All political activities are strictly prohibited on FN premises. FN encourages all of its employees to vote and to participate in the election process, but these activities must not be performed using FN assets or resources.
  9. Harassment – FN strives to maintain a workplace free of harassment and that is sensitive to the diversity of its employees. Therefore, FN prohibits the use of computers, e-mail, voice mail, instant messaging, texting and the Internet in ways that are disruptive, offensive to others, or harmful to morale. For example, the display or transmission of sexually explicit images, messages, and cartoons is strictly prohibited. Other examples of misuse includes, but is not limited to, ethnic slurs, racial comments, off-color jokes, or anything that may be construed as harassing, discriminatory, derogatory, defamatory, threatening or showing disrespect for others.
  10. Junk E-mail - All communications using IT resources shall be purposeful and appropriate. Distributing “junk” mail, such as chain letters, advertisements, or unauthorized solicitations is prohibited. A chain letter is defined as a letter sent to several persons with a request that each send copies of the letter to an equal number of persons. Advertisements offer services from someone else to you. Solicitations are when someone asks you for something. If you receive any of the above, delete the e-mail message immediately. Do not forward the e-mail message to anyone.

Generally, while it is NOT the policy of FN to monitor the content of any electronic communication, FN is responsible for servicing and protecting FN’s equipment, networks, data, and resource availability and therefore may be required to access and/or monitor electronic communications from time to time. Several different methods are employed to accomplish these goals. For example, an audit or cost analysis may require reports that monitor phone numbers dialed, length of calls, number of calls to / from a specific handset, the time of day, etc. Other examples where electronic communications may be monitored include, but are not limited to, research and testing to optimize IT resources, troubleshooting technical problems and detecting patterns of abuse or illegal activity.

FN reserves the right, at its discretion, to review any employee’s files or electronic communications to the extent necessary to ensure all electronic media and services are used in compliance with all applicable laws and regulations as well as FN policies.

Employees should structure all electronic communication with recognition of the fact that the content could be monitored, and that any electronic communication could be forwarded, intercepted, printed or stored by others.

Internet Access

Internet access is provided for FN users and is considered a great resource for the organization and is required for Employees to perform their duties. This resource is costly to operate and maintain, and must be allocated primarily to those with business, administrative or contract needs. The Internet access provided by FN should not be used for entertainment, listening to music, viewing the sports highlight of the day, games, movies, etc.

Many Internet sites, such as games, peer-to-peer file sharing applications, chat rooms, and on-line music sharing applications, have already been blocked by FN firewalls. This list is constantly monitored and updated as necessary. Any employee visiting pornographic sites will be disciplined and may be terminated. All Internet activity from FN devices and networks is logged and can be filtered if it is found to violate laws, regulations or FN policies.

Reporting Software Malfunctions

Users should inform the appropriate FN personnel when the user's software does not appear to be functioning correctly. The malfunction - whether accidental or deliberate - may pose an information security risk. If the user, or the user's manager or supervisor, suspects a computer virus infection, FN computer virus policy should be followed, and these steps should be taken immediately:

  • Stop using the computer
  • Do not carry out any commands, including commands to Save data.
  • Do not close any of the computer's windows or programs.
  • Do not turn off the computer or peripheral devices.
  • If possible, physically disconnect the computer from networks to which it is attached.
  • Inform the appropriate personnel or FN IS Admin as soon as possible. Write down any unusual behavior of the computer (screen messages, unexpected disk access, unusual responses to commands) and the time when they were first noticed.
  • Write down any changes in hardware, software, or software use that preceded the malfunction.
  • Do not attempt to remove a suspected virus!
  • The ISO should monitor the resolution of the malfunction or incident, and report to the CST the result of the action with recommendations on action steps to avert future similar occurrences.

Report Security Incidents

It is the responsibility of each FN employee or contractor to report perceived security incidents on a continuous basis to the appropriate supervisor or security person. A User is any person authorized to access an information resource. Users are responsible for the day-to-day, hands-on security of that resource. Users are to formally report all security incidents or violations of the security policy immediately to the Privacy Officer and their direct supervisor.  Users should report any perceived security incident to either their immediate supervisor, or to their department head, or to any member of FN CST. Members of the CST are specified above in this document.

Reports of security incidents shall be escalated as quickly as possible. Each member of FN CST must inform the other members as rapidly as possible. Each incident will be analyzed to determine if changes in the existing security structure are necessary. All reported incidents are logged and the remedial action indicated. It is the responsibility of the CST to provide training on any procedural changes that may be required as a result of the investigation of an incident.

Security breaches shall be promptly investigated. If criminal action is suspected, FN Privacy Officer shall contact the appropriate law enforcement and investigative authorities immediately, which may include but is not limited to the police or the FBI.

Transfer of Sensitive/Confidential Information

When confidential or sensitive information from one individual is received by another individual while conducting official business, the receiving individual shall maintain the confidentiality or sensitivity of the information in accordance with the conditions imposed by the providing individual. All employees must recognize the sensitive nature of data maintained by FN and hold all data in the strictest confidence. Any purposeful release of data to which an employee may have access is a violation of FN policy and will result in personnel action, and may result in legal action.

Transferring Software and Files between Home and Work

Personal software shall not be used on FN computers or networks. If a need for specific software exists, submit a request to your supervisor or department head. Users shall not use FN purchased software on home or on non-FN computers or equipment.

FN proprietary data, including but not limited to patient information, IT Systems information, financial information or human resource data, shall not be placed on any computer that is not the property of FN without written consent of the respective supervisor or department head. It is crucial to FN to protect all data and, in order to do that effectively we must control the systems in which it is contained. In the event that a supervisor or department head receives a request to transfer FN data to a non-FN Computer System, the supervisor or department head should notify the Privacy Officer or appropriate personnel of the intentions and the need for such a transfer of data.

FN Wide Area Network (“WAN”) is maintained with a wide range of security protections in place, which include features such as virus protection, e-mail file type restrictions, firewalls, anti-hacking hardware and software, etc. Since FN does not control non-FN personal computers, FN cannot be sure of the methods that may or may not be in place to protect FN sensitive information, hence the need for this restriction.

FN staff may use their own mobile devices (BYOD) on the Guest Wireless LAN and will never contain any ePHI information or direct access to ePHI systems. BYOD devices are allowed to access the internet only and do not have direct access to internal systems. Staff-owned mobile computers being used in official FN duties are required to have FN-managed security software installed before being connected to the corporate network. Employees are required to notify Management of any breeches or loss of personal mobile devices which have been used in an official business capacity.

Internet Considerations

Special precautions are required to block Internet (public) access to FN information resources not intended for public access, and to protect confidential FN and Client information when it is to be transmitted over the Internet.

The following security and administration issues shall govern Internet usage on all production computers connected to FN networks. This policy does not apply to computers used in a LAB environment or under development for deployment to a Client.

Prior approval of FN Privacy Officer or appropriate personnel authorized by FN shall be obtained before:

  • An Internet, or other external network connection, is established;
  • FN information (including notices, memoranda, documentation and software) is made available on any Internet-accessible computer (e.g. web or ftp server) or device;
  • Users may not install or download any software (applications, screen savers, etc.). If users have a need for additional software, the user is to contact their supervisor;
  • Use shall be consistent with the goals of FN. The network can be used to market services related to FN, however use of the network for personal profit or gain is prohibited.
  • Confidential or sensitive data - including credit card numbers, telephone calling card numbers, logon passwords, and other parameters that can be used to access goods or services - shall be encrypted before being transmitted through the Internet.
  • The encryption software used, and the specific encryption keys (e.g. passwords, pass phrases), shall be escrowed with FN Privacy Officer or appropriate personnel, to ensure they are safely maintained/stored. The use of encryption software and keys, which have not been escrowed as prescribed above, is prohibited, and may make the user subject to disciplinary action.

Installation of authentication and encryption certificates on the e-mail system

Any user desiring to transfer secure e-mail with a specific identified external user may request to exchange public keys with the external user. Once verified, the certificate is installed on both recipients’ workstations, and the two may safely exchange secure e-mail.

Use of WinZip encrypted and zipped e-mail

This software allows FN personnel to exchange e-mail with remote users who have the appropriate encryption software on their system. The two users exchange private keys that will be used to both encrypt and decrypt each transmission. Any FN staff member who desires to utilize this technology may request this software from the Privacy Officer or IS Administrator.

De-identification / Re-identification of Personal Health Information (PHI)

As Policy, FN will not store or exchange ePHI data. This is done via FN’s BA. We defer to BA policy.

Policy and Procedure


PP #: IS-1.2

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS008, TVS015, TVS016, TVS023)

Identification and Authentication

User Logon IDs

Individual users shall have unique logon IDs and passwords. An access control system shall identify each user and prevent unauthorized users from entering or using information resources. Security requirements for user identification include:

Each user shall be assigned a unique identifier.

Users shall be responsible for the use and misuse of their individual logon ID.

All user login IDs are audited at least twice yearly and all inactive logon IDs are revoked. FN Human Resources Department notifies the Security Officer or appropriate personnel upon the departure of all employees and contractors, at which time login IDs are revoked.

The logon ID is locked or revoked after a maximum of three (3) unsuccessful logon attempts which then require the passwords to be reset by the appropriate Administrator.

Users who desire to obtain access to FN systems or networks must have a completed and signed Network Access Form (Appendix C). This form must be signed by the supervisor or department head of each user requesting access.


User Account Passwords

User IDs and passwords are required in order to gain access to all FN networks and workstations. All passwords are restricted by a corporate-wide password policy to be of a "Strong" nature. This means that all passwords must conform to restrictions and limitations that are designed to make the password difficult to guess. Users are required to select a password in order to obtain access to any electronic information both at the server level and at the workstation level. When passwords are reset, the user will be automatically prompted to manually change that assigned password.

Password Length – Passwords are required to be a minimum of eight characters.

Content Requirements - Passwords must contain a combination of upper and lower case alphabetic characters, numeric characters, and special characters.

Change Frequency –Passwords change every 90 days. Where 2phase authentication is being employed, passcodes are unique with every login. See Note below.

Reuse – Passwords are not reused up to 5 times. See Note below for 2phase authentication statement where used.

Restrictions on Sharing Passwords - Passwords shall not be shared, written down on paper, or stored within a file or database on a workstation and must be kept confidential.

Restrictions on Recording Passwords - Passwords are masked or suppressed on all online screens, and are never printed or included in reports or logs. Passwords are stored in an encrypted format.

NOTE –where 2phase authentication is used, which requires a token that changes at each login, password policy exceeds HIPAA requirements.

Confidentiality Agreement

Users of FN information resources shall sign, as a condition for employment, an appropriate confidentiality agreement (Appendix B). The agreement shall include the following statement, or a paraphrase of it:

I understand that any unauthorized use or disclosure of information residing on Insert FN Name information resource systems may result in disciplinary action consistent with the policies and procedures of federal, state, and local agencies.

Temporary workers and third-party employees not already covered by a confidentiality agreement shall sign such a document prior to accessing FN information resources.

Confidentiality agreements shall be reviewed when there are changes to contracts or other terms of employment, particularly when contracts are ending or employees are leaving an organization.

Access Control

Information resources are protected by the use of access control systems. Access control systems include both internal (i.e. passwords, encryption, access control lists, constrained user interfaces, etc.) and external (i.e. port protection devices, firewalls, host-based authentication, etc.).

Rules for access to resources (including internal and external telecommunications and networks) have been established by the information/application owner or manager responsible for the resources. Access by employees is granted by request to the Security Officer or IS Administrator. Access by outside personnel is only granted by the completion of a Network Access Request Form (Appendix C). This form can only be initiated by the appropriate department head, and must be signed by the department head and the Security Officer or appropriate personnel.

This guideline satisfies the "need to know" requirement of the HIPAA regulation, since the supervisor or department head is the person who most closely recognizes an employee's need to access data. Users may be added to the information system, network, or EHR only upon the signature of the Security Officer or appropriate personnel who is responsible for adding the employee to the network in a manner and fashion that ensures the employee is granted access to data only as specifically requested.

Online banner screens, if used, shall contain statements to the effect that unauthorized use of the system is prohibited and that violators will be subject to criminal prosecution.

Identification and Authentication Requirements

The host security management program shall maintain current user application activity authorizations. Each initial request for a connection or a session is subject to the authorization process previously addressed.

User Login Entitlement Reviews

If an employee changes positions at FN, employee’s new supervisor or department head shall promptly notify the Information Technology (“IT”) Department of the change of roles. This can be done by indicating on the Network Access Request Form (Appendix C) both the roles or access that need to be added and the roles or access that need to be removed so that employee has access to the minimum necessary data to effectively perform their new job functions. The effective date of the position change should also be noted on the Form so that the IT Department can ensure that the employee will have appropriate roles, access, and applications for their new job responsibilities. For a limited training period, it may be necessary for the employee who is changing positions to maintain their previous access as well as adding the roles and access necessary for their new job responsibilities.

No less than annually, the IT Manager shall facilitate entitlement reviews with department heads to ensure that all employees have the appropriate roles, access, and software necessary to perform their job functions effectively while being limited to the minimum necessary data to facilitate HIPAA compliance and protect patient data.

Termination of User Logon Account

Upon termination of an employee, whether voluntary or involuntary, employee’s supervisor or department head shall promptly notify the IT Department. This can be done by indicating “Remove Access” on the employee’s Network Access Request Form (Appendix C) and submitting the Form to the IT Department. If employee’s termination is voluntary and employee provides notice, employee’s supervisor or department head shall promptly notify the IT Department of employee’s last scheduled work day so that their user account(s) can be configured to expire. The employee’s department head shall be responsible for insuring that all keys, ID badges, and other access devices as well as FN equipment and property is returned to FN prior to the employee leaving FN on their final day of employment.

No less than quarterly, the IT Manager or their designee shall provide a list of active user accounts for both network and application access to department heads for review. Department heads shall review the employee access lists ASAP. If any of the employees on the list are no longer employed by FN, the department head will immediately notify the IT Department of the employee’s termination status. This may be done by submitting an updated Network Access Request Form (Appendix C).

Policy and Procedure


PP #: IS-1.3

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Network Connectivity

Dial-In Connections

Access to FN information resources through modems or other dial-in devices / software, if available, shall be subject to authorization and authentication by an access control system. Direct inward dialing without passing through the access control system is prohibited.

Dial-up numbers shall be unlisted.

Systems that allow public access to host computers, including mission-critical servers, warrants additional security at the operating system and application levels. Such systems shall have the capability to monitor activity levels to ensure that public usage does not unacceptably degrade system responsiveness.

Dial-up access privileges are granted only upon the request of a department head with the submission of the Network Access Form and the approval of the Privacy Officer or appropriate personnel.

Dial Out Connections

FN provides a link to an Internet Service Provider. If a user has a specific need to link with an outside computer or network through a direct link, approval must be obtained from the Privacy Officer or appropriate personnel. The appropriate personnel will ensure adequate security measures are in place.

Telecommunication Equipment

Certain direct link connections may require a dedicated or leased phone line. These facilities are authorized only by the Privacy Officer or appropriate personnel and ordered by the appropriate personnel. Telecommunication equipment and services include but are not limited to the following:

  • phone lines
  • fax lines
  • calling cards
  • phone head sets
  • software type phones installed on workstations
  • conference calling contracts
  • cell phones
  • Blackberry type devices
  • call routing software
  • call reporting software
  • phone system administration equipment
  • T1/Network lines
  • long distance lines
  • 800 lines
  • local phone lines
  • PRI circuits
  • telephone equipment

Permanent Connections

The security of FN systems can be jeopardized from third party locations if security practices and resources are inadequate. When there is a need to connect to a third party location, a risk analysis should be conducted. The risk analysis should consider the type of access required, the value of the information, the security measures employed by the third party, and the implications for the security of FN systems. The Privacy Officer or appropriate personnel should be involved in the process, design and approval.

Emphasis on Security in Third Party Contracts

Access to FN computer systems or corporate networks should not be granted until a review of the following concerns have been made, and appropriate restrictions or covenants included in a Statement of Work (“SOW”) with the party requesting access.

Applicable sections of FN Information Security Policy have been reviewed and considered.

Policies and standards established in FN information security program have been enforced.

A risk assessment of the additional liabilities that will attach to each of the parties to the agreement.

The right to audit contractual responsibilities should be included in the agreement or SOW.

Arrangements for reporting and investigating security incidents must be included in the agreement in order to meet the covenants of the HIPAA Business Associate Agreement.

A description of each service to be made available.

Each service, access, account, and/or permission made available should only be the minimum necessary for the third party to perform their contractual obligations.

A detailed list of users that have access to FN computer systems must be maintained and auditable.

If required under the contract, permission should be sought to screen authorized users.

­Dates and times when the service is to be available should be agreed upon in advance.

Procedures regarding protection of information resources should be agreed upon in advance and a method of audit and enforcement implemented and approved by both parties.

The right to monitor and revoke user activity should be included in each agreement.

Language on restrictions on copying and disclosing information should be included in all agreements.

Responsibilities regarding hardware and software installation and maintenance should be understood and agreement upon in advance.

Measures to ensure the return or destruction of programs and information at the end of the contract should be written into the agreement.

If physical protection measures are necessary because of contract stipulations, these should be included in the agreement.

A formal method to grant and authorized users who will access to the data collected under the agreement should be formally established before any users are granted access.

Mechanisms should be in place to ensure that security measures are being followed by all parties to the agreement.

Because annual confidentiality training is required under the HIPAA regulation, a formal procedure should be established to ensure that the training takes place, that there is a method to determine who must take the training, who will administer the training, and the process to determine the content of the training established.

A detailed list of the security measures which will be undertaken by all parties to the agreement should be published in advance of the agreement.


Authority from the Privacy Officer or appropriate personnel must be received before any employee or contractor is granted access to a FN router or firewall. Outside contractor(s) who have access to Firewall(s) or router(s) will operate under a valid BA and will be verified to meet or exceed HIPPA standards.

Policy and Procedure


PP #: IS-1.4

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Malicious Code

Antivirus Software Installation

Antivirus software is installed on all FN personal computers and servers. Virus update patterns are updated daily on FN servers and workstations. Virus update engines and data files are monitored by appropriate administrative staff that is responsible for keeping all virus patterns up to date.

Configuration - The antivirus software currently implemented by FN is FN Anti-Virus. Updates are received via an approved method as they are released and approved.

Remote Deployment Configuration - Through an automated procedure, updates and virus patches may be pushed out to the individual workstations and servers on an as needed basis. This is not dependent on geographic location.

Monitoring/Reporting – A record of virus patterns for all workstations and servers on FN network may be maintained. Appropriate administrative staff is responsible for providing reports for auditing and emergency situations as requested by the Privacy Officer or appropriate personnel.

New Software Distribution

Only software created by FN application staff, if applicable, or software approved by the Privacy Officer or IS Admin will be used on internal computers and networks. All new software will be tested by appropriate personnel in order to ensure compatibility with currently installed software and network configuration. In addition, only approved staff have permission to install applications on FN computers. This includes shrink-wrapped software procured directly from commercial sources as well as shareware and freeware obtained from electronic bulletin boards, the Internet, or on disks (magnetic or CD-ROM and custom-developed software).

Although shareware and freeware can often be useful sources of work-related programs, the use and/or acquisition of such software must be approved by the Privacy Officer or appropriate personnel. Because the software is often provided in an open distribution environment, special precautions must be taken before it is installed on FN computers and networks. These precautions include determining that the software does not, because of faulty design, “misbehave” and interfere with or damage FN hardware, software, or data, and that the software does not contain viruses, either originating with the software designer or acquired in the process of distribution.

All data and program files that have been electronically transmitted to a FN computer or network from another location must be scanned for viruses immediately after being received. Contact the appropriate FN personnel for instructions for scanning files for viruses.

Every diskette, CD-ROM, DVD and USB device is a potential source for a computer virus. Therefore, every diskette, CD-ROM, DVD and USB device must be scanned for virus infection prior to copying information to a FN computer or network.

Computers shall never be “booted” from a diskette, CD-ROM, DVD or USB device received from an outside source. Users shall always remove any diskette, CD-ROM, DVD or USB device from the computer when not in use. This is to ensure that the diskette, CD-ROM, DVD or USB device is not in the computer when the machine is powered on. A diskette, CD-ROM, DVD or USB device infected with a boot virus may infect a computer in that manner, even if the diskette, CD_ROM, DVD or USB device is not “bootable”.

Retention of Ownership

All software programs and documentation generated or provided by employees, consultants, or contractors for the benefit of FN are the property of FN unless covered by a contractual agreement which states otherwise. Nothing contained herein applies to software purchased by FN employees at their own expense.



Policy and Procedure


PP #: IS-1.5

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS012, TVS015)



Encryption is the translation of data into a secret code. Encryption is the most effective way to achieve data security. To read an encrypted file, you must have access to a secret key or password that enables you to decrypt it. Unencrypted data is called plain text; encrypted data is referred to as cipher text. Encryption is required for all ePHI data in production or at rest.

Encryption Key

An encryption key specifies the particular transformation of plain text into cipher text, or vice versa during decryption.

If justified by risk analysis, sensitive data and files shall be encrypted before being transmitted through networks. When encrypted data are transferred between agencies, the agencies shall devise a mutually agreeable procedure for secure key management. In the case of conflict, FN shall establish the criteria in conjunction with the Privacy Officer or appropriate personnel. FN employs several methods of secure data transmission.

Installation of authentication and encryption certificates on the e-mail system

Any user desiring to transfer secure e-mail with a specific identified external user may request to exchange public keys with the external user by contacting the Privacy Officer or appropriate personnel. Once verified, the certificate is installed on each recipient workstation, and the two may safely exchange secure e-mail.

Use of WinZip encrypted and zipped e-mail

This software allows FN personnel to exchange e-mail with remote users who have the appropriate encryption software on their system. The two users exchange private keys that will be used to both encrypt and decrypt each transmission. Any FN staff member who desires to utilize this technology may request this software from the Privacy Officer or appropriate personnel.


File Transfer Protocol (FTP)

Files may be transferred to secure FTP sites through the use of appropriate security precautions. Requests for any FTP transfers should be directed to the Privacy Officer or appropriate personnel.

Secure Socket Layer (SSL) Web Interface

Any EHR hosted (ASP) system, if applicable, will require access to a secure SSL website. Any such access must be requested using the Network Access Request Form (found in Appendix A) and have appropriate approval from the supervisor or department head as well as the Privacy Officer or appropriate personnel before any access is granted.


Policy and Procedure


PP #: IS-1.6

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS009, TVS010)

Building Security

It is the policy of FN to provide building access in a secure manner. Each site, if applicable, is somewhat unique in terms of building ownership, lease contracts, entranceway access, fire escape requirements, and server room control. However, FN strives to continuously upgrade and expand its security and to enhance protection of its assets and medical information that has been entrusted to it. The following list identifies measures that are in effect at FN. All other facilities, if applicable, have similar security appropriate for that location.

FN is located at FN Address.

Main Building entrance is locked after-hours and the code changes regularly.

All production and private office areas are restricted access and are locked when not in use. Only non-restricted areas are the Reception area and Conference room(s).

Entrance to the FN portion of the building during non-working hours is only allowed by management-level employees. Where door access control system is used, non-management-level employees are tracked by digital ID.

The door to the production area is locked at all times and requires appropriate credentials or escort past the reception or waiting area door(s). Where door access control system is used, all FN employees are given a digital ID for entrance to the production area. Digital ID is non-transferable and all employees have signed a use-policy thereby recognizing their responsibilities and penalties for digital ID use.

The reception area is staffed at all times during the working hours of 8:00 AM to 5:00 PM. Any unrecognized person in a restricted office location should be challenged as to their right to be there. All visitors must sign in at the front desk, wear a visitor badge, and be accompanied by a FN staff member. In some situations, non-FN personnel, who have signed the confidentiality agreement, do not need to be accompanied at all times.

All FN ingress/egress points are continuously monitored and recorded by video surveillance.

Fire Protection: Use of local building codes will be observed. Manufacturer’s recommendations on the fire protection of individual hardware will be followed.


Policy and Procedure


PP #: IS-1.7

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology


With the increased availability of broadband access and VPNs, telecommuting has become more viable for many organizations. FN considers telecommuting to be an acceptable work arrangement in certain circumstances. This policy is applicable to all employees and contractors who work either permanently or only occasionally outside of FN office environment. It applies to users who work from their home full time, to employees on temporary travel, to users who work from a remote office location, and to any user who connects to FN network and/or hosted EHR, if applicable, from a remote location.

While telecommuting can be an advantage for users and for the organization in general, it presents new risks in the areas of confidentiality and security of data. Workers linked to FN’s network become an extension of the wide area network and present additional environments that must be protected against the danger of spreading Trojans, viruses, or other malware. This arrangement also exposes the corporate as well as patient data to risks not present in the traditional work environment.

General Requirements

Telecommuting workers are required to follow all corporate, security, confidentiality, HR, or Code of Conduct policies that are applicable to other employees/contractors.

Need to Know: Telecommuting Users will have the access based on the same ‘need to know’ as they have when in the office.

Password Use: Auth Anvil 2FA password use changes every login and is used for telecommuters.

Training: Personnel who telecommute must complete the same annual privacy training as all other employees.

Contract Specific: There may be additional requirements specific to the individual contracts to which an employee is assigned.

Required Equipment

Employees approved for telecommuting must understand that FN will not provide all equipment necessary to ensure proper protection of information to which the employee has access.

Hardware Security Protections

Virus Protection: Home users must never stop the update process for Virus Protection. Virus Protection software is installed on all FN personal computers and is set to update the virus pattern on a daily basis. This update is critical to the security of all data, and must be allowed to complete.


VPN and Firewall Use: Established procedures must be rigidly followed when accessing FN information of any type. FN requires the use of VPN software or a firewall device in order to directly access any internal LAN resources that have not been published for outside access. Disabling a virus scanner or firewall is reason for termination.


Lock Screens: No matter what location, always lock the screen before walking away from the workstation. The data on the screen may be protected by HIPAA or may contain confidential information. Be sure the automatic lock feature has been set to automatically turn on after 15 minutes of inactivity.

Data Security Protection

Data Backup: Backup procedures have been established that encrypt the data being moved to an external media. Use only that procedure – do not create one on your own. If there is not a backup procedure established, or if you have external media that is not encrypted, contact the appropriate FN personnel for assistance. Protect external media by keeping it in your possession when traveling.


Transferring Data to FN: Transferring of data to FN requires the use of an approved VPN or SSL Encrypted connection to ensure the confidentiality and integrity of the data being transmitted. Do not circumvent established procedures, nor create your own method, when transferring data to/from FN.

External System Access: If you require access to an external system, contact your supervisor or department head. Privacy Officer or appropriate personnel will assist in establishing a secure method of access to the external system.


E-mail: Do not send any individual-identifiable information (PHI or PII) via e-mail unless it is encrypted. If you need assistance with this, contact the Privacy Officer or appropriate personnel to ensure an approved encryption mechanism is used for transmission through e-mail.


Non-FN Networks: Extreme care must be taken when connecting FN equipment to a home or hotel network. Although FN actively monitors its security status and maintains organization wide protection policies to protect the data within all contracts, FN has no ability to monitor or control the security procedures on non-FN networks. FN does not currently allow direct connectivity to FN networks from non-FN networks. All work performed from non-FN networks is performed via encrypted RDS or SSL web-based applications.

Protect Data in Your Possession: View or access only the information that you have a need to see to complete your work assignment. Regularly review the data you have stored to ensure that no ePHI level data is kept and that old data is eliminated as soon as possible. Store electronic data only in encrypted work spaces. If your laptop has not been set up with an encrypted work space, contact the Privacy Officer or appropriate personnel for assistance.


Hard Copy Reports or Work Papers: Never leave paper records around your work area. Lock all paper records in a file cabinet at night or when you leave your work area.


Data Entry When in a Public Location: Do not perform work tasks which require the use of sensitive corporate or patient level information when you are in a public area, i.e. airports, airplanes, hotel lobbies. Computer screens can easily be viewed from beside or behind you.


Sending Data Outside FN: All external transfer of data must be associated with an official contract, non-discloser agreement, or appropriate Business Associate Agreement. Do not give or transfer any patient level information to anyone outside FN without the written approval of your supervisor.

Disposal of Paper and/or External Media

Shredding: All paper which contains sensitive information that is no longer needed must be shredded before being disposed. Do not place in a trash container without first shredding. All employees working from home, or other non-FN work environment, MUST have direct access to a shredder.


Disposal of Electronic Media: All external media must be sanitized or destroyed in accordance with HIPAA compliant procedures.

Do not throw any media containing sensitive, protected information in the trash.

Return all external media to your supervisor

External media must be wiped clean of all data. The Privacy Officer or appropriate personnel has very definitive procedures for doing this – so all external media must be sent to them.

The final step in this process is to forward the media for disposal by a certified destruction agency.


Policy and Procedure


PP #: IS-1.8

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Specific Protocols and Devices

Wireless Usage Standards and Policy

Due to an emergence of wireless access points in hotels, airports, and in homes, it has become imperative that a Wireless Usage policy be developed and adopted to ensure the security and functionality of such connections for FN employees. This policy outlines the processes and procedures for acquiring wireless access privileges, utilizing wireless access, and ensuring the security of FN laptops and mobile devices.

Approval Procedure - In order to be granted the ability to utilize the wireless network interface on your FN laptop or mobile device you will be required to gain the approval of your immediate supervisor or department head and the Privacy Officer or appropriate personnel of FN. The Network Access Request Form (found in Appendix A) is used to make such a request. Once this form is completed and approved you will be contacted by appropriate FN personnel to setup your laptop and schedule training.

Software Requirements - The following is a list of minimum software requirements for any FN laptop that is granted the privilege to use wireless access:

  • Windows 10 with current patches or later Operating System (Firewall enabled when not connected to secured, internal network)
  • FN supplied Antivirus software
  • Full Disk Encryption (even If not storing ePHI information)
  • Approved VPN FN (if applicable)
  • MS Edge Chromium

If your laptop does not have all of these software components, please notify your supervisor or department head so these components can be installed.

Training Requirements - Once you have gained approval for wireless access on your FN computer, you will be required to attend a usage and security training session to be provided by the Privacy Officer or appropriate personnel. This training session will cover the basics of connecting to wireless networks, securing your computer when connected to a wireless network, and the proper method for disconnecting from wireless networks. This training will be conducted within a reasonable period of time once wireless access approval has been granted, and in most cases will include several individuals at once.

Use of Transportable Media

Transportable media included within the scope of this policy includes, but is not limited to, SD cards, DVDs, CD-ROMs, and USB key devices.

FN will never transport ePHI on transportable media for any reason. Any data transfer will take place as a direct file transfer over acceptably encrypted channels.

The purpose of this policy is to guide employees/contractors of FN in the proper use of transportable

media when a legitimate business requirement exists to transfer data to and from FN networks. Every workstation or server that has been used by either FN employees or contractors is presumed to have sensitive information stored on its hard drive. Therefore procedures must be carefully followed when copying data to or from transportable media to protect sensitive FN data. Since transportable media, by their very design are easily lost, care and protection of these devices must be addressed. Since it is very likely that transportable media will be provided to a FN employee by an external source for the exchange of information, it is necessary that all employees have guidance in the appropriate use of media from other companies.

The use of transportable media in various formats is common practice within FN. All users must be aware that sensitive data could potentially be lost or compromised when moved outside of FN networks. Transportable media received from an external source could potentially pose a threat to FN networks. Sensitive data includes all human resource data, financial data, FN proprietary information, and personal health information (“PHI”) protected by the Health Insurance Portability and Accountability Act (“HIPAA”).

USB key devices are handy devices which allow the transfer of data in an easy to carry format. They provide a much improved format for data transfer when compared to previous media formats, like diskettes, CD-ROMs, or DVDs. The software drivers necessary to utilize a USB key are normally included within the device and install automatically when connected. They now come in a rugged titanium format which connects to any key ring. These factors make them easy to use and to carry, but unfortunately easy to lose.

Rules governing the use of transportable media include:

  • No sensitive data should ever be stored on transportable media unless the data is maintained in an encrypted format.
  • All USB keys used to store FN data or sensitive data must be an encrypted USB key issued by the Privacy Officer or appropriate personnel. The use of a personal USB key is strictly prohibited.
  • Users must never connect their transportable media to a workstation that is not issued by FN.
  • Non-FN workstations and laptops may not have the same security protection standards required by FN, and accordingly virus patterns could potentially be transferred from the non-FN device to the media and then back to FN workstation.
  • Example: Do not copy a work spreadsheet to your USB key and take it home to work on your home PC.
  • Data may be exchanged between FN workstations/networks and workstations used within FN. The very nature of data exchange requires that under certain situations data be exchanged in this manner.
  • Examples of necessary data exchange include:
  • Data provided to auditors via USB key during the course of the audit.

It is permissible to connect transferable media from other businesses or individuals into FN workstations or servers as long as the source of the media is known to the employee and is trusted.

Before initial use and before any sensitive data may be transferred to transportable media, the media must be sent to the Privacy Officer or appropriate personnel to ensure appropriate and approved encryption is used. Copy sensitive data only to the encrypted space on the media. Non-sensitive data may be transferred to the non-encrypted space on the media.

Report all loss of transportable media to your supervisor or department head. It is important that the CST team is notified either directly from the employee or contractor or by the supervisor or department head immediately.

When an employee leaves FN, all transportable media in their possession must be returned to the Privacy Officer or appropriate personnel for data erasure that conforms to US Department of Defense standards for data elimination.

FN utilizes an approved method of encrypted data(EFS) to ensure that all data is converted to a format that cannot be decrypted. The Privacy Officer or appropriate personnel can quickly establish an encrypted partition on your transportable media.

When no longer in productive use, all FN laptops, workstation, or servers must be wiped of data in a manner which conforms to HIPAA regulations. All transportable media must be wiped according to the same standards. Thus all transportable media must be returned to the Privacy Officer or appropriate personnel for data erasure when no longer in use.

Policy and Procedure


PP #: IS-1.9

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS020, TVS021)

Retention / Destruction of Medical Information

FN will not destroy any data containing Medical Information. BA/Data Owner will follow BA Policy for destroying Data.

Many state and federal laws regulate the retention and destruction of medical information. FN actively conforms to these laws and follows the strictest regulation if/when a conflict occurs.

Record Retention - Documents relating to uses and disclosures, authorization forms, business partner contracts, notices of information practice, responses to a patient who wants to amend or correct their information, the patient's statement of disagreement, and a complaint record are maintained for a period of 6 years.

Record Destruction - All hardcopy medical records that require destruction are shredded using NIST 800-88 guidelines.

Policy and Procedure


PP #: IS-1.10

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS020, TVS021)

Disposal of External Media / Hardware

Disposal of External Media

It must be assumed that any external media in the possession of an employee is likely to contain either protected health information (“PHI”) or other sensitive information. Accordingly, external media (CD-ROMs, DVDs, diskettes, USB drives) should be disposed of in a method that ensures that there will be no loss of data and that the confidentiality and security of that data will not be compromised.

The following steps must be adhered to:

It is the responsibility of each employee to identify media which should be shredded and to utilize this policy in its destruction.

External media should never be thrown in the trash.

When no longer needed all forms of external media are to be sent to the Privacy Officer or appropriate personnel for proper disposal.

The media will be secured until appropriate destruction methods are used based on NIST 800-88 guidelines.

Requirements Regarding Equipment

All equipment to be disposed of will be wiped of all data, and all settings and configurations will be reset to factory defaults. No other settings, configurations, software installation or options will be made. Asset tags and any other identifying logos or markings will be removed.

Disposition of Excess Equipment

As the older FN computers and equipment are replaced with new systems, the older machines are held in inventory for a wide assortment of uses:

  • Older machines are regularly utilized for spare parts.
  • Older machines are used on an emergency replacement basis.
  • Older machines are used for testing new software.
  • Older machines are used as backups for other production equipment.
  • Older machines are used when it is necessary to provide a second machine for personnel who travel on a regular basis.
  • Older machines are used to provide a second machine for personnel who often work from home.


Policy and Procedure


PP #: IS-1.11

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Change Management

Statement of Policy

To ensure that FN is tracking changes to networks, systems, and workstations including software releases and software vulnerability patching in information systems that contain electronic protected health information (“ePHI”). Change tracking allows the Information Technology (“IT”) Department to efficiently troubleshoot issues that arise due to an update, new implementation, reconfiguration, or other change to the system.


  1. The IT staff or other designated FN employee who is updating, implementing, reconfiguring, or otherwise changing the system shall carefully log all changes made to the system.
  2. When changes are tracked within a system, i.e. Windows updates in the Add or Remove Programs component or electronic health record (EHR) updates performed and logged by the vendor, changes are tracked through an approved system, such as ticketing or RMM logging.
  3. The employee implementing the change will ensure that all necessary data backups are performed prior to the change.
  4. The employee implementing the change shall also be familiar with the rollback process in the event that the change causes an adverse effect within the system and needs to be removed.


Policy and Procedure


PP #: IS-1.12

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS013, TVS014, TVS019)

Audit Controls

Statement of Policy

To ensure FN implements hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain electronic protected health information (“ePHI”). Audit Controls are technical mechanisms that track and record computer activities. An audit trail determines if a security violation occurred by providing a chronological series of logged computer events that relate to an operating system, an application, or user activities.

Where appropriate, FN is committed to taking reasonable steps to continually assess potential risks and vulnerabilities to ePHI in its possession. As such, FN will continually assess potential risks and vulnerabilities to ePHI in its possession and develop, implement, and maintain appropriate administrative, physical, and technical security measures in accordance with the HIPAA Security Rule.


  1. See policy entitled Information System Activity Review for the administrative safeguards for auditing system activities.
  2. The Information Technology Services shall enable event auditing on all computers that process, transmit, and/or store ePHI for purposes of generating audit logs. Each audit log shall include, at a minimum: user ID, login time and date, and scope of patient data being accessed for each attempted access. Audit trails shall be stored on a separate computer system to minimize the impact of such auditing on business operations and to minimize access to audit trails.
  3. FN shall utilize appropriate network-based and host-based intrusion detection systems where appropriate.
Policy and Procedure


PP #: IS-1.13

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS014, TVS017, TVS019)

Information System Activity Review

Statement of Policy

To establish the process for conducting, on a periodic basis, an operational review of system activity including, but not limited to, user accounts, system access, file access, security incidents, audit logs, and access reports. Where appropriate, FN is committed to taking reasonable steps to review records of system activity to minimize security violations.


  1. See policy entitled Audit Controls for a description of the technical mechanisms that track and record activities on Fluid’s information systems that contain or use ePHI.
  2. The Information Technology Services shall be responsible for conducting reviews of Fluid’s information systems’ activities. Such person(s) shall have the appropriate technical skills with respect to the operating system and applications to access and interpret audit logs and related information appropriately.

All significant findings shall be recorded and dealt with in an appropriate manner.



Policy and Procedure


PP #: IS-1.14

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology
(TVS012, TVS013)

Data Integrity

Statement of Policy

FN has NO ownership or control of ePHI and defers to BA’s Data Integrity Policies.


To the fullest extent possible, FN will not alter or destroy BA ePHI data. BA is responsible for any movement or destruction of ePHI

FN shall acquire appropriate network-based and host-based intrusion detection systems. The Security Officer shall be responsible for installing, maintaining, and updating such systems.

To prevent transmission errors as data passes from one computer to another, FN will use encryption, as determined to be appropriate, to preserve the integrity of data.

FN will check for possible duplication of data in its computer systems to prevent poor data integration between different computer systems.

To prevent programming or software bugs, FN will test its information systems for accuracy and functionality before it starts to use them. FN will update its systems when IT vendors release fixes to address known bugs or problems.

  1. FN will install and regularly update antivirus software on all workstations to detect and prevent malicious code from altering or destroying data.
  2. To prevent exposing magnetic media to a strong magnetic field, workforce members shall keep magnetic media away from strong magnetic fields and heat. For example, computers should not be left in automobiles during the summer months.


Policy and Procedure


PP #: IS-1.15

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Contingency Plan

Statement of Policy

To establish and implement policies and procedures for responding to an emergency or other occurrence (e.g., fire, vandalism, system failure, natural disaster) that damages systems that contain ePHI.

FN is committed to maintaining formal practices for responding to an emergency or other occurrence that damages systems containing ePHI. FN shall continually assess potential risks and vulnerabilities to protect health information in its possession, and develop, implement, and maintain appropriate administrative, physical, and technical security measures in accordance with the HIPAA Security Rule.


Data Backup Plan

FN, under the direction of the Security Officer, shall implement a data backup plan to create and maintain retrievable exact copies of ePHI.

FN’s Standard Procedure for backing up data is a full snapshot of the ePHI is taken nightly for 2 weeks. It is stored per BA  Policy.

Backups are not stored on removable media. Any Offsite copies of backup data is sent in an encrypted stream and stored in an encrypted file.

Authorized personnel shall test backup procedures on an regular basis to ensure that exact copies of ePHI can be retrieved and made available. Such testing shall be documented where authorized personnel can reference easily. To the extent such testing indicates need for improvement in backup procedures, the Security Officer shall identify and implement such improvements in a timely manner.

Disaster Recovery and Emergency Mode Operations Plan  

The Security Officer shall be responsible for developing and regularly updating the written disaster recovery and emergency mode operations plan for the purpose of:

  • Restoring or recovering any loss of ePHI and/or systems necessary to make ePHI available in a timely manner caused by fire, vandalism, terrorism, system failure, or other emergency; and  
  • Continuing operations during such time information systems are unavailable. Such written plan  shall have a sufficient level of detail and explanation that a person unfamiliar with the system can implement the plan in case of an emergency or disaster. Copies of the plan shall be maintained on-site and at the off-site locations at which backups are stored or other secure off-site location.

The disaster recovery and emergency mode operation plan shall include the following:

  • Current copies of the information systems inventory and network configuration developed and updated as part of FN’s risk analysis.  
  • Current copy of the written backup procedures developed and updated pursuant to this policy.
  • An inventory of hard copy forms and documents needed to record clinical, registration, and financial interactions with patients.
  • Identification of an emergency response team. Members of such team shall be responsible for the following:
  • Determining the impact of a disaster and/or system unavailability on  Fluid’s operations.
  • In the event of a disaster, securing the site and providing ongoing physical security.
  • Retrieving lost data.
  • Identifying and implementing appropriate “work-around’s” during such time information systems are unavailable.
  • Taking such steps necessary to restore operations.

Procedures for responding to loss of electronic data including, but not limited to retrieval and loading of backup data or methods for recreating data should backup data be unavailable. The procedures should identify the order in which data is to be restored based on the criticality analysis performed as part of  Fluid’s risk analysis.

Telephone numbers and/or e-mail addresses for all persons to be contacted in the event of a disaster, including the following:

  • Members of the immediate response team,
  • Facilities at which backup data is stored,
  • Information systems vendors, and
  • All current workforce members.

The disaster recovery team shall meet on at least an annual basis to:

  • Review the effectiveness of the plan in responding to any disaster or emergency experienced by  Fluid;
  • In the absence of any such disaster or emergency, plan drills to test the effectiveness of the plan and evaluate the results of such drills; and
  • Review the written disaster recovery and emergency mode operations plan and make appropriate changes to the plan. The Security Officer shall be responsible for convening and maintaining minutes of such meetings. The Security Officer also shall be responsible for revising the plan based on the recommendations of the disaster recovery team.



Policy and Procedure


PP #: IS-1.16

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Security Awareness and Training

Statement of Policy

To establish a security awareness and training program for all members of FN’s workforce, including management.

All workforce members shall receive appropriate training concerning FN’s security policies and procedures. Such training shall be provided prior to the effective date of the HIPAA Security Rule and on an ongoing basis to all new employees. Such training shall be repeated annually for all employees.



Security Training Program

The Security Officer shall have responsibility for the development and delivery of initial security training. All workforce members shall receive such initial training addressing the requirements of the HIPAA Security Rule including the updates to HIPAA regulations found in the Health Information Technology for Economic and Clinical Health (HITECH) Act. Security training shall be provided to all new workforce members as part of the orientation process. Attendance and/or participation in such training shall be mandatory for all workforce members. The Security Officer shall be responsible for maintaining appropriate documentation of all training activities.

The Security Officer shall have responsibility for the development and delivery of ongoing security training provided to workforce members in response to environmental and operational changes impacting the security of ePHI, e.g., addition of new hardware or software, and increased threats.


Security Reminders

The Security Officer shall generate and distribute to all workforce members routine security reminders on a regular basis. Periodic reminders shall address password security, malicious software, incident identification and response, and access control. The Security Officer may provide such reminders through formal training, e-mail messages, and discussions during staff meetings, screen savers, log-in banners, newsletter/intranet articles, posters, promotional items such as coffee mugs, mouse pads, sticky notes, etc. The Security Officer shall be responsible for maintaining appropriate documentation of all periodic security reminders.

The Security Officer shall generate and distribute special notices to all workforce members providing urgent updates, such as new threats, hazards, vulnerabilities, and/or countermeasures.

Protection from Malicious Software

As part of the aforementioned Security Training Program and Security Reminders, the Security Officer shall provide training concerning the prevention, detection, containment, and eradication of malicious software. Such training shall include the following:

  • Guidance on opening suspicious e-mail attachments, e-mail from unfamiliar senders, and hoax e-mail,
  • The importance of updating anti-virus software and how to check a workstation or other device to determine if virus protection is current,
  • Instructions to never download files from unknown or suspicious sources,
  • Recognizing signs of a potential virus that could sneak past antivirus software or could arrive prior to an update to anti-virus software,
  • The importance of backing up critical data on a regular basis and storing the data in a safe place,
  • Damage caused by viruses and worms, and
  • What to do if a virus or worm is detected.

Password Management

As part of the aforementioned Security Training Program and Security Reminders, the Security Officer shall provide training concerning password management. Such training shall address the importance of confidential passwords in maintaining computer security, as well as the following requirements relating to passwords:

  • Passwords must be changed every 90 days.
  • A user cannot reuse the last 5 passwords.
  • Passwords must be at least eight characters and contain upper case letters, lower case letters, numbers, and special characters.
  • Commonly used words, names, initials, birthdays, or phone numbers should not be used as passwords.
  • A password must be promptly changed if it is suspected of being disclosed, or known to have been disclosed.
  • Passwords must not be disclosed to other workforce members (including anyone claiming to need a password to “fix” a computer or handle an emergency situation) or individuals, including family members.
  • Passwords must not be written down, posted, or exposed in an insecure manner such as on a notepad or posted on the workstation.

Employees should refuse all offers by software and/or Internet sites to automatically login the next time that they access those resources.

Any employee who is directed by the Security Officer to change his/her password to conform to the aforementioned standards shall do so immediately.



Policy and Procedure


PP #: IS-1.17

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Security Management Process

Statement of Policy

To ensure FN conducts an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI held by FN.

FN shall conduct an accurate and thorough risk analysis to serve as the basis for FN’s HIPAA Security Rule compliance efforts. FN shall re-assess the security risks to its ePHI and evaluate the effectiveness of its security measures and safeguards as necessary in light of changes to business practices and technological advancements.



The Security Officer shall be responsible for coordinating  FN’s risk analysis. The Security Officer shall identify appropriate persons within the organization to assist with the risk analysis.

The risk analysis shall proceed in the following manner:

  • Document  FN’s current information systems used for ePHI access.
  • Update/develop information systems inventory. List the following information for all hardware (i.e., network devices, workstations, printers, scanners, mobile devices) and  software (i.e., operating system, various applications, interfaces): date acquired, location, vendor, licenses, maintenance schedule, and function. Update/develop network diagram illustrating how organization’s information system network is configured.
  • Update/develop facility layout showing location of all information systems equipment, power sources, telephone jacks, and other telecommunications equipment, network access points, fire and burglary alarm equipment, and storage for hazardous materials.

For each application identified, identify each licensee (i.e., authorized user) by job title and describe the manner in which authorization is granted.

For each application identified:

  • Describe the data associated with that application.
  • Determine whether the data is created by the organization or received from a third party. If data is received from a third party, identify that party and the purpose and manner of receipt.
  • Determine whether the data is maintained within the organization only or transmitted to third parties. If data is transmitted to a third party, identify that party and the purpose and manner of transmission.
  • Define the criticality of the application and related data as high, medium, or low. Criticality is the degree of impact on the organization if the application and/or related data were unavailable for a period of time.
  • Define the sensitivity of the data as high, medium, or low. Sensitivity is the nature of the data and the harm that could result from a breach of confidentiality or security incident.

For each application identified, identify the various security controls currently in place and locate any written policies and procedures relating to such controls.

Identify and document threats to the confidentiality, integrity, and availability (referred to as “threat agents”) of ePHI created, received, maintained, or transmitted by  FN. Consider the following:

  • Natural threats, e.g., earthquakes, storm damage.
  • Environmental threats, e.g., fire and smoke damage, power outage, utility problems.
  • Human threats
  • Accidental acts, e.g., input errors and omissions, faulty application programming or processing procedures, failure to update/upgrade software/security devices, lack of adequate financial and human resources to support necessary security controls
  • Inappropriate activities, e.g., inappropriate conduct, abuse of privileges or rights, workplace violence, waste of corporate assets, harassment
  • Illegal operations and intentional attacks, e.g., eavesdropping, snooping, fraud, theft, vandalism, sabotage, blackmail
  • External attacks, e.g., malicious cracking, scanning, demon dialing, virus introduction
  • Identify and document vulnerabilities in  FN’s information systems. A vulnerability is a flaw or weakness in security policies and procedures, design, implementation, or controls that could be accidentally triggered or intentionally exploited, resulting in unauthorized access to ePHI, modification of ePHI, denial of service, or repudiation (i.e., the inability to identify the source and hold some person accountable for an action). To accomplish this task, conduct a self-analysis utilizing the standards and implementation specifications to identify vulnerabilities.
  • Determine and document probability and criticality of identified risks.
  • Assign probability level, i.e., likelihood of a security incident involving identified risk.
    • "Very Likely" (3) is defined as having a probable chance of occurrence.
    • "Likely" (2) is defined as having a significant chance of occurrence.
    • "Not Likely" (1) is defined as a modest or insignificant chance of occurrence.
  • Assign criticality level.
    • "High" (3) is defined as having a catastrophic impact on the medical practice including a significant number of medical records which may have been lost or compromised.
    • "Medium" (2) is defined as having a significant impact including a moderate number of medical records within FN which may have been lost or compromised.
    • "Low" (1) is defined as a modest or insignificant impact including the loss or compromise of some medical records.
  • Determine risk score for each identified risk. Multiply the probability score and criticality score. Those risks with a higher risk score require more immediate attention.
  • Identify and document appropriate security measures and safeguards to address key vulnerabilities. To accomplish this task, review the vulnerabilities you have identified in relation to the standards and implementation specifications. Focus on those vulnerabilities with high risk scores, as well as specific security measures and safeguards required by the Security Rule.
  • Develop and document an implementation strategy for critical security measures and safeguards.
  • Determine timeline for implementation.
  • Determine costs of such measures and safeguards and secure funding.
  • Assign responsibility for implementing specific measures and safeguards to appropriate person(s).
  • Make necessary adjustments based on implementation experiences.
  • Document actual completion dates.
  • Evaluate effectiveness of measures and safeguards following implementation and make appropriate adjustments.

The Security Officer shall be responsible for identifying appropriate times to conduct follow-up evaluations and coordinating such evaluations. The Security Officer shall identify appropriate persons within the organization to assist with such evaluations. Such evaluations shall be conducted upon the occurrence of one or more of the following events: changes in the HIPAA Security Regulations; new federal, state, or local laws or regulations affecting the security of ePHI; changes in technology, environmental processes, or business processes that may affect HIPAA Security policies or procedures; or the occurrence of a serious security incident. Follow-up evaluations shall include the following:

Inspections, reviews, interviews, and analysis to assess adequacy of administrative and physical safeguards. Such evaluation shall include interviews to assess employee compliance; after-hours walk-through inspections to assess physical security, password protection (i.e., not posted), and workstation sessions terminated (i.e., employees logged out); review of latest security policies and procedures for correctness and completeness; and inspection and analysis of training, incident, and media logs for compliance.

Analysis to assess adequacy of controls within the network, operating systems and applications. As appropriate, FN shall engage outside vendors to evaluate existing physical and technical security measures and make recommendations for improvement.

Policy and Procedure


Emergency Operations Procedures

(EHR outage)

PP #: IS-2.0

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Emergency Operations Procedures


BA provides procedures for managing and documenting patient encounters when Electronic Health Record (EHR) and Management Systems are unavailable due to planned or unexpected outages.




The Information Systems or Technology Manager shall notify FN management and BA as soon as practicable in the event of:

  • Planned downtime of EHR systems,
  • Unexpected outage of EHR systems, and
  • Resumption of EHR services following an outage such that normal operations may resume.


Policy and Procedure

Title: Emergency Access “Break the Glass”

PP #: IS-3.0

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

Emergency Access “Break the Glass”

Policy Summary

FN has no access to patient data for emergency access. BA provides this access. FN defers to BA Policy. If FN gains access to ePHI for any reason, appropriate and reasonable policies will be developed and followed.


Policy and Procedure

Title: Sanction Policy
Security Violations and Disciplinary Action

PP #: IS-4.0

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Human Resources

21 Sanction Policy

It is the policy of FN that all workforce members must protect the confidentiality, integrity, and availability of sensitive information at all times. FN will impose sanctions, as described below, on any individual who accesses, uses, or discloses sensitive information without proper authorization.

FN will take appropriate disciplinary action against employees, contractors, or any individuals who violate FN’s information security and privacy policies or state, or federal confidentiality laws or regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA).


To ensure that there are appropriate sanctions that will be applied to workforce members who violate the requirements of HIPAA, FN’s security policies, Directives, and/or any other state or federal regulatory requirements.


Workforce member means employees, volunteers, and other persons whose conduct, in the performance of work for a covered entity, is under the direct control of such entity, whether or not they are paid by the covered entity. This includes full and part time employees, affiliates, associates, volunteers, and staff from third party entities who provide service to the covered entity.

Sensitive information, includes, but not limited to, the following:

  • Protected Health Information (PHI) – Individually identifiable health information that is in any form or media, whether electronic, paper, or oral.
  • Electronic Protected Health Information (ePHI) – PHI that is in electronic format.
  • Personnel files – Any information related to the hiring and/or employment of any individual who is or was employed by FN.
  • Payroll data – Any information related to the compensation of an individual during that individuals’ employment with FN.
  • Financial/accounting records – Any records related to the accounting practices or financial statements of FN.
  • Other information that is confidential – Any other information that is sensitive in nature or considered to be confidential.

Availability refers to data or information is accessible and useable upon demand by an authorized person.

Confidentiality refers to data or information is not made available or disclosed to unauthorized persons or processes.

Integrity refers to data or information that have not been altered or destroyed in an unauthorized manner.



Listed below are the types of violations that require sanctions to be applied. They are stated at levels 1, 2, and 3 depending on the seriousness of the violation.


Description of Violation


Accessing information that you do not need to know to do your job.

Sharing computer access codes (user name password).

Leaving computer unattended while being able to access sensitive information.

Disclosing sensitive information with unauthorized persons.

Copying sensitive information without authorization.

Changing sensitive information without authorization.

Discussing sensitive information in a public area or in an area where the public could overhear the conversation.

Discussing sensitive information with an unauthorized person.

Failing/refusing to cooperate with the Information Security Officer, Privacy Officer, Chief Information Officer, and/or authorized designee.


Second occurrence of any Level 1 offense (does not have to be the same offense).

Unauthorized use or disclosure of sensitive information.

Using another person's computer access code (user name password).

Failing/refusing to comply with a remediation resolution or recommendation.


Third occurrence of any Level 1 offense (does not have to be the same offense).

Second occurrence of any Level 2 offense (does not have to be the same offense).

Obtaining sensitive information under false pretenses.

Using and/or disclosing sensitive information for commercial advantage, personal gain, or malicious harm.

Recommended Disciplinary Actions

In the event that a workforce member violates FN’s privacy and security policies and/or violates the Health Insurance Portability and Accountability Act of 1996 (HIPAA) or related state laws governing the protection of sensitive and patient identifiable information, the following recommended disciplinary actions will apply.

Violation Level

Recommended Disciplinary Action


Verbal or written reprimand

Retraining on privacy/security awareness

Retraining on FN’s privacy and security policies

Retraining on the proper use of internal or required forms


Letter of Reprimand*; or suspension

Retraining on privacy/security awareness

Retraining on FN’s privacy and security policies

Retraining on the proper use of internal or required forms


Termination of employment or contract

Civil penalties as provided under HIPAA or other applicable Federal/State/Local law

Criminal penalties as provided under HIPAA or other applicable Federal/State/Local law

  • ImportantNote: The recommended disciplinary actions are identified in order to provide guidance in policy enforcement and are not meant to be all-inclusive. If formal discipline is deemed necessary, FN shall consult with Human Resources prior to taking action. When appropriate, progressive disciplinary action steps shall be followed allowing the employee to correct the behavior which caused the disciplinary action.

*A Letter of Reprimand must be reviewed by Human Resources before given to the employee.



Depending on the severity of the violation, any single act may result in disciplinary action up to and including termination of employment or contract with FN.


U.S. Department of Health and Human Services

Health Information Privacy. Retrieved April 24, 2009, from



Policy and Procedure

Title: Reporting and Managing a Privacy Breach Procedure

PP #: IS-6.0

Approval Date: 12-3-13

Review: Annual

Effective Date: 1-1-14

Information Technology

22. Breach Notification Procedures


To outline the process for notifying affected individuals of a breach of protected information under the Privacy Act, unsecured protected health information (PHI) for the purposes of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Health Information Technology for Economic and Clinical Health Act (HITECH), and/or state breach notification purposes.


This applies to all employees, volunteers, and other individuals working under contractual agreements with FN.


State Breach – Unauthorized acquisition or reasonable belief of unauthorized acquisition of Personal Information that compromises the security, confidentiality, or integrity of the Personal Information.

Personal Information – Personal Information has many definitions including definitions by statute which may vary from state to state. Most generally, Personal Information is a combination of data elements which could uniquely identify an individual. Please review applicable state data breach statutes to determine what definition of Personal Information is applicable for purposes of the document.

HIPAA Breach – Unauthorized acquisition, access, use, or disclosure of unsecured PHI.

Personally Identifiable Information (PII) – Information in any form that consists of a combination of an individual’s name and one or more of the following: Social Security Number, driver’s license or state ID, account numbers, credit card numbers, debit card numbers, personal code, security code, password, personal ID number, photograph, fingerprint, or other information which could be used to identify an individual.

Individually Identifiable Health Information (IIHI) – PII which includes information related to the past, present or future condition, treatment, payment or provision of health care to the identified individual.

Privacy Act Breach – Unauthorized acquisition or reasonable belief of unauthorized acquisition of personal information protected by the Privacy Act. This information includes, but is not limited to Social Security Number, government issued ID numbers, financial account numbers or other information posing a risk of identity theft.

Private Information – Information protected by the Privacy Act, Personally Identifiable Information, Personal Information and Protected Health Information collectively.

Protected Health Information (PHI) – Individually identifiable health information except for education records covered by FERPA and employment records.



Reporting a Possible Breach  

  • Any employee who becomes aware of a possible breach of privacy involving Private Information in the custody or control of FN will immediately inform their supervisor/manager, and the Privacy Officer.
  • Notification should occur immediately upon discovery of a possible breach or before the end of your shift if other duties interfere, however, in no case should notification occur later than twenty-four (24) hours after discovery.
    • The supervisor/manager will verify the circumstances of the possible breach and inform the Privacy Officer and the division Administrator/Director within twenty-four (24) hours of the initial report.
  • You may call the Privacy Officer directly at 805-856-1736
    • Provide the Privacy Officer with as much detail as possible.
    • Be responsive to requests for additional information from the Privacy Officer.
    • Be aware that the Privacy Officer has an obligation to follow up on any reasonable belief that Private Information has been compromised.
  • The Privacy Officer, in conjunction with FN’s Legal Counsel, will decide whether or not to notify the President/CEO as appropriate by taking into consideration the seriousness and scope of the breach.

Containing the Breach

  • The Privacy Officer will take the following steps to limit the scope and effect of the breach.
    • Work with department(s) to immediately contain the breach. Examples include, but are not limited to:
  • Stopping the unauthorized practice
  • Recovering the records, if possible
  • Shutting down the system that was breached
  • Mitigating the breach, if possible
  • Correcting weaknesses in security practices
  • Notifying the appropriate authorities including the local Police Department if the breach involves, or may involve, any criminal activity

Investigating and Evaluating the Risks Associated with the Breach

  • To determine what other steps are immediately necessary, the Privacy Officer in collaboration with FN’s Legal Counsel and affected department(s) and administration, will investigate the circumstances of the breach.
    • A team will review the results of the investigation to determine root cause(es), evaluate risks, and develop a resolution plan.
  • The Privacy Breach Assessment tool will help aid the investigation.
    • The Privacy Officer, in collaboration with FN’s Legal Counsel, will consider several factors in determining whether to notify individuals affected by the breach including, but not limited to:
  • Contractual obligations
  • Legal obligations – FN’s Legal Counsel should complete a separate legal assessment of the potential breach and provide the results of the assessment to the Privacy Officer and the rest of the breach response team
  • Risk of identity theft or fraud because of the type of information lost such as social security number, banking information, identification numbers
  • Risk of physical harm if the loss puts an individual at risk of stalking or harassment
  • Risk of hurt, humiliation, or damage to reputation when the information includes medical or disciplinary records
  • Number of individuals affected


  • The Privacy Officer will work with the department(s) involved, FN’s Legal Counsel and appropriate leadership to decide the best approach for notification and to determine what may be required by law.
  • If required by law, notification of individuals affected by the breach will occur as soon as possible following the breach.
    • Affected individuals must be notified without reasonable delay, but in no case later than sixty (60) calendar days after discovery, unless instructed otherwise by law enforcement or other applicable state or local laws.
  • Notices must be in plain language and include basic information, including:
  • What happened
  • Types of PHI involved
  • Steps individuals should take
  • Steps covered entity is taking
  • Contact Information
  • Notices should be sent by first-class mail or if individual agrees electronic mail. If insufficient or out-of-date contact information is available, then a substitute notice is required as specified below.
    • If law enforcement authorities have been contacted, those authorities will assist in determining whether notification may be delayed in order not to impede a criminal investigation.
  • The required elements of notification vary depending on the type of breach and which law is implicated. As a result, FN’s Privacy Officer and Legal Counsel should work closely to draft any notification that is distributed.
  • Indirect notification such as website information, posted notices, media will generally occur only where direct notification could cause further harm, or contact information is lacking.
    • If a breach affects five-hundred (500) or more individuals, or contact information is insufficient, FN will notify a prominent media outlet that is appropriate for the size of the location with affected individuals, and notice will be provided in the form of a press release.
  • Using multiple methods of notification in certain cases may be the most effective approach.

Business associates must notify FN if they incur or discover a breach of unsecured PHI.

  • Notices must be provided without reasonable delay and in no case later than sixty (60) days after discovery of the breach.
  • Business associates must cooperate with FN in investigating and mitigating the breach.
  • Notice to Health and Human Services (HHS) as required by HIPAA – If FN’s Legal Counsel determines that HIPAA notification is not required; this notice is also not required.
  • Information regarding breaches involving five-hundred (500) or more individuals, regardless of location, must be submitted to HHS at the same time that notices to individuals are issued.
  • If a breach involves fewer than five-hundred (500) individuals, FN will be required to keep track of all breaches and to notify HHS within sixty (60) days after the end of the calendar year.


  • Once immediate steps are taken to mitigate the risks associated with the breach, the Privacy Officer will investigate the cause of the breach.  
    • If necessary, this will include a security audit of physical, organizational, and technological measures.
    • This may also include a review of any mitigating steps taken.
  • The Privacy Officer will assist the responsible department to put into effect adequate safeguards against further breaches.
  • Procedures will be reviewed and updated to reflect the lessons learned from the investigation and regularly thereafter.
  • The resulting plan will also include audit recommendations, if appropriate.

Compliance and Enforcement

All managers and supervisors are responsible for enforcing these procedures. Employees who violate these procedures are subject to discipline up to and including termination in accordance with FN’s Sanction Policy.

Related Policies

IS-2.0 Sanction Policy

All Employees and Officers are required to have a signed Acknowledgement of Fluid’s Information Security Policy on record (Appendix B). If you do not have a form on file, please click the link on Appendix B and follow the directions there to submit your signed Acknowledgement.

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