The Security Officer is responsible for facilitating the training and supervision of all workforce members [164.308(a)(3)(ii)(A) and 164.308(a)(5)(ii)(A)], investigation and sanctioning of any workforce member that is in violation of LifeWIRE security policies and non-compliance with the security regulations [164.308(a)(1)(ii)(c)], and writing, implementing, and maintaining all polices, procedures, and documentation related to efforts toward security and compliance [164.316(a-b)].
The current LifeWIRE Security Officer is Chico Marvici (firstname.lastname@example.org).
5.3.1 Organizational Responsibilities
The Security Officer, in collaboration with the Privacy Officer, is responsible for facilitating the development, testing, implementation, training, and oversight of all activities pertaining to LifeWIRE’s efforts to be compliant with the HIPAA Security Regulations, HITRUST CSF, and any other security and compliance frameworks. The intent of the Security Officer Responsibilities is to maintain the confidentiality, integrity, and availability of ePHI. The Security Officer is appointed by and reports to the CEO.
These organizational responsibilities include, but are not limited to the following:
1. Oversees and enforces all activities necessary to maintain compliance and verifies the activities are in alignment with the requirements.
2. Helps to establish and maintain written policies and procedures to comply with the Security rule and maintains them for six years from the date of creation or date it was last in effect, whichever is later.
3. Reviews and updates policies and procedures as necessary and appropriate to maintain compliance and maintains changes made for six years from the date of creation or date it was last in effect, whichever is later.
4. Facilitates audits to validate compliance efforts throughout the organization.
5. Documents all activities and assessments completed to maintain compliance and maintains documentation for six years from the date of creation or date it was last in effect, whichever is later.
6. Provides copies of the policies and procedures to management, customers, and partners, and has them available to review by all other workforce members to which they apply.
7. Annually, and as necessary, reviews and updates documentation to respond to environmental or operational changes affecting the security and risk posture of ePHI stored, transmitted, or processed within LifeWIRE infrastructure.
8. Develops and provides periodic security updates and reminder communications for all workforce members.
9. Implements procedures for the authorization and/or supervision of workforce members who work with ePHI or in locations where it may be accessed.
10. Maintains a program promoting workforce members to report non-compliance with policies and procedures.
- Promptly, properly, and consistently investigates and addresses reported violations and takes steps to prevent recurrence.
- Applies consistent and appropriate sanctions against workforce members who fail to comply with the security policies and procedures of LifeWIRE.
- Mitigates, to the extent practicable, any harmful effect known to LifeWIRE of a use or disclosure of ePHI in violation of LifeWIRE’s policies and procedures, even if effect is the result of actions of LifeWIRE business associates, customers, and/or partners.
11. Reports security efforts and incidents to administration immediately upon discovery. Responsibilities in the case of a known ePHI breach are documented in the LifeWIRE Breach Policy.
12. The Security Officer facilitates the communication of security updates and reminders to all workforce members to which it pertains. Examples of security updates and reminders include, but are not limited to:
- Latest malicious software or virus alerts;
- LifeWIRE’s requirement to report unauthorized attempts to access ePHI;
- Changes in creating or changing passwords;
- Additional security-focused training is provided to all workforce members by the Security Officer. This training includes, but is not limited to:
- Data backup plans;
- System auditing procedures;
- Redundancy procedures;
- Contingency plans;
- Virus protection;
- Patch management;
- Media Disposal and/or Re-use;
- Documentation requirements.
13. The Security Officer works with the COO to ensure that any security objectives have appropriate consideration during the budgeting process.
- In general, security and compliance are core to LifeWIRE’s technology and service offerings; in most cases this means security-related objectives cannot be split out to separate budget line items.
- For cases that can be split out into discrete items, such as licenses for commercial tooling, the Security Officer follows LifeWIRE’s standard corporate budgeting process.
- At the beginning of every fiscal year, the COO contacts the Security Officer to plan for the upcoming year’s expenses.
- The Security Officer works with the COO to forecast spending needs based on the previous year’s level, along with changes for the upcoming year such as additional staff hires.
- During the year, if an unforeseen security-related expense arises that was not in the budget forecast, the Security Officer works with the COO to reallocate any resources as necessary to cover this expense.
14. Annual reporting. The Security Officer, together with the Privacy Officer shall prepare and present an annual report to the HR and Governance Committee of the LifeWIRE Board of Directors. This report shall include a review of the Security Program, the Business Risk Analysis, together with the IT Risk Analysis as well as results of tabletop Disaster Recovery exercises. The report shall also include a summary of any Breach, any Incidences and any significant Intrusion detection findings.
5.3.2 Supervision of Workforce Responsibilities
Although the Security Officer is responsible for implementing and overseeing all activities related to maintaining compliance, it is the responsibility of all workforce members (i.e. team leaders, supervisors, managers, directors, co-workers, etc.) to supervise all workforce members and any other user of LifeWIRE’s systems, applications, servers, workstations, etc. that contain ePHI.
- Monitor workstations and applications for unauthorized use, tampering, and theft and report non-compliance according to the Security Incident Response policy.
- Assist the Security and Privacy Officers to ensure appropriate role-based access is provided to all users.
- Take all reasonable steps to hire, retain, and promote workforce members and provide access to users who comply with the Security regulation and LifeWIRE’s security policies and procedures.
5.3.3 Sanctions of Workforce Responsibilities
All workforce members report non-compliance of LifeWIRE’s policies and procedures to the Security Officer or other individual as assigned by the Security Officer within 24 hours of the discovery of non-compliance. Individuals that report violations in good faith may not be subjected to intimidation, threats, coercion, discrimination against, or any other retaliatory action as a consequence.
1. The Security Officer promptly facilitates a thorough investigation of all reported violations of LifeWIRE’s security policies and procedures. The Security Officer may request the assistance from others.
- Complete an audit trail/log to identify and verify the violation and sequence of events.
- Interview any individual that may be aware of or involved in the incident.
- All individuals are required to cooperate with the investigation process and provide factual information to those conducting the investigation.
- Provide individuals suspected of non-compliance of the Security rule and/or LifeWIRE’s policies and procedures the opportunity to explain their actions.
- The investigator thoroughly documents the investigation as the investigation occurs. This documentation must include a list of all employees involved in the violation.
2. Violation of any security policy or procedure by workforce members may result in corrective disciplinary action, up to and including termination of employment. Violation of this policy and procedures by others, including business associates, customers, and partners may result in termination of the relationship and/or associated privileges. Violation may also result in civil and criminal penalties as determined by federal and state laws and regulations.
- A violation resulting in a breach of confidentiality (i.e. release of PHI to an unauthorized individual), change of the integrity of any ePHI, or inability to access any ePHI by other users, requires immediate termination of the workforce member from LifeWIRE.
3. The Security Officer facilitates taking appropriate steps to prevent recurrence of the violation (when possible and feasible).
4. In the case of an insider threat, the Security Officer and Privacy Officer are to set up a team to investigate and mitigate the risk of insider malicious activity. LifeWIRE workforce members are encouraged to come forward with information about insider threats, and can do so anonymously.
5. The Security Officer maintains all documentation of the investigation, sanctions provided, and actions taken to prevent reoccurrence for a minimum of six years after the conclusion of the investigation.