Cybersecurity Management Policy

Purpose

To establish a comprehensive framework that ensures the confidentiality, integrity, and availability of electronic Protected Health Information (ePHI) in compliance with applicable laws and regulations.

Scope

This policy applies to all staff members who have access to ePHI, including employees, contractors, and business associates.

Policy Sections

1. Risk/Vulnerability Assessment

  • Procedure:
    • An annual risk/vulnerability assessment will be conducted to evaluate the effectiveness of existing safeguards for ePHI.
    • Assessments should identify potential vulnerabilities and recommend remedial actions.
    • Document findings and provide a report to management.

2. Authenticity

  • Procedure:
    • All users accessing ePHI are required to implement Two-Factor Authentication (2FA) during the login process.
    • Users must be instructed on how to set up and maintain 2FA as part of their security training.

3. Assigned Security Responsibility

  • Procedure:
    • Designate a Security Officer responsible for writing, implementing, and enforcing all security policies.
    • The Security Officer will act as the primary contact for security-related inquiries and incident responses.

4. Information Access Management

  • Procedure:
    • Maintain a detailed access control list indicating which users have access to ePHI.
    • Conduct an annual user access audit to confirm that access levels align with job responsibilities and ensure least privilege principles are followed.
    • Document any access changes and the rationale for those changes.

5. Security Awareness and Training

  • Procedure:
    • Provide security awareness training to all employees annually and conduct training sessions, including online sessions through platforms like Wizer.
    • Keep records of training attendance and provide additional training as necessary for new or updated policies.

6. Security Incident Procedures

  • Procedure:
    • In the event of a security incident, the response team will document the incident, outlining timeline, actions taken, and outcomes.
    • Conduct a post-incident review to assess and improve response strategies.
    • Ensure all documentation is maintained for audit purposes.

7. Contingency Plan

  • Procedure:
    • Develop a comprehensive Contingency Plan outlining procedures for backing up ePHI, data restoration, and maintaining critical business functions during emergencies.
    • Regularly test the contingency plan to ensure effectiveness and update as necessary.

8. Evaluation

  • Procedure:
    • Assign a responsible individual to perform annual technical and non-technical assessments of policies and security systems.
    • Document the results of these assessments and ensure they are communicated to relevant stakeholders.

9. Business Associate Contracts

  • Procedure:
    • Before engaging with any new vendor or business associate, ensure they sign a Business Associate Agreement (BAA) confirming compliance with all security and privacy laws and regulations.
    • Review existing contracts annually to ensure continued compliance.

Conclusion

This Security Management Policy outlines procedures necessary for protecting electronic Protected Health Information (ePHI), ensuring compliance, and safeguarding sensitive data. Adherence to these policies is essential for maintaining the trust of patients and the integrity of the organization.

Review and Updates

This policy will be reviewed annually and updated as necessary to reflect changes in regulations, technology, or organizational priorities.

10/24/2025