Introduction

C3LX, Inc (“C3LX") is committed to ensuring the confidentiality, privacy, integrity, and availability of all electronic protected health information (ePHI) it receives, maintains, processes and/or transmits on behalf of its Users and Clients (“Customers”).

C3LX provides secure and compliant cloud-based software. This hosted software falls into two broad categories: 1) Health and Wellness Applications (Apps) and 2) Population Health Management & Reporting (Tools). These Categories are cited throughout polices as Customers in each category inherit different policies, procedures, and obligations from C3LX.

As providers of disease-specific, patient-facing health and wellness software, C3LX strives to maintain compliance, proactively address information security, mitigate risk for its Customers, and assure known breaches are completely and effectively communicated in a timely manner. The following documents address core policies used by C3LX to maintain compliance and assure the proper protections of infrastructure used to store, process, and transmit ePHI for C3LX Customers.

License

C3LX HIPAA policies have been adapted from the Catalyze, Inc. open-source HIPAA policies.

The original policies can be found, hosted by Catalyze, here.

The adapted policies can be found, hosted by C3LX, here.

All policies are licensed under CC BY-SA 4.0

Health and Wellness Applications (Apps)

Apps Customers utilize hosted software from C3LX to input and store personal health data. Customers also communicate with C3LX employed health coaches (“Coaches”) within the software. These apps are deployed into compliant containers run on systems secured and managed by Aptible, Inc (“Aptible”). Aptible does not have insight or access into application level data of Apps Customers and, as such, does not have the ability to secure or manage risk associated with application level vulnerabilities and security weaknesses. With Apps, C3LX has access to data models and manages all application level configurations and security. C3LX makes every effort to reduce the risk of unauthorized disclosure, access, and/or breach of Apps Customer data through network (firewalls, dedicated IP spaces, etc) and server settings (encryption at rest and in transit, Threatstack throughout the Platform, etc).

Population Health Management & Reporting (Tools)

Tools are compliant services that are offered as part of the Apps. These services currently include our Health Coach Platform (Patient Monitoring and secure Messaging Service) and Friends & Family Platform (Single Patient Monitoring). With Tools, C3LX has access to data models and manages all application level configurations and security.

In the future there may be 3rd party Add-on services available as part of the C3LX Apps and Tools (“Platform”). These 3rd party, or Partner, Services will be fully reviewed by C3LX to assure they do not have a negative impact on C3LX's information security and compliance posture.

Compliance Inheritance

C3LX signs business associate agreements (BAAs) with its 3rd party providers (“Providers”). These BAAs outline C3LX's obligations and Provider obligations, as well as liability in the case of a breach. In providing infrastructure and managing security configurations that are a part of the technology requirements that exist in HIPAA and HITRUST, as well as future compliance frameworks, C3LX does not manage any aspects of compliance for Providers.

Certain aspects of compliance cannot be inherited. Because of this, C3LX Providers, in order to achieve full compliance or HITRUST Certification, must implement certain organizational policies. These policies and aspects of compliance fall outside of the services and obligations of C3LX.

Version Control

Policies were last updated September 13th, 2016.

Policy Management Policy

C3LX implements policies and procedures to maintain compliance and integrity of data. The Security Officer and Privacy Officer are responsible for maintaining policies and procedures and assuring all C3LX workforce members, business associates, customers, and partners are adherent to all applicable policies. Previous versions of policies are retained to assure ease of finding policies at specific historic dates in time.

Applicable Standards from the HITRUST Common Security Framework

  • 12.c - Developing and Implementing Continuity Plans Including Information Security

Applicable Standards from the HIPAA Security Rule

  • 164.316(a) - Policies and Procedures
  • 164.316(b)(1)(i) - Documentation

Maintenance of Policies

  1. All policies are stored and up to date to maintain C3LX compliance with HIPAA, HITRUST, and other relevant standards. Updates and version control are done similar to source code control using Github.
  2. Policy update requests can be made by any workforce member at any time. Furthermore, all policies are reviewed annually by both the Security and Privacy Officer to assure they are accurate and up-to-date.
  3. Edits and updates made by appropriate and authorized workforce members are done on their own versions, or branches. These changes are only merged back into final, or master, versions by the Privacy or Security Officer, similar to a pull request. All changes are linked to workforce personnel who made them and the Officer who accepted them.
  4. All policies are made accessible to all C3LX workforce members. The current master policies are published here. (www.c3lx.com/policies)

    • Changes can be requested to policies using this form. (Google Form)
    • Once the change has been approved to a C3LX Policy we implement the policy change using Salt. The process for that is spelled out in the C3LX Configuration Management Policy.
    • Changes are automatically communicated to all C3LX team members through integrations between Github and Slack that log all Github policy channels to a dedicated C3LX Slack Channel.
  5. All policies, and associated documentation, are retained for 6 years from the date of its creation or the date when it last was in effect, whichever is later

    1. Version history of all C3LX policies is done via Github.
    2. Backup storage of all policies is done with Box.
  6. The policies and information security policies are reviewed and audited annually. Issues that come up as part of this process are reviewed by C3LX management to assure all risks and potential gaps are mitigated and/or fully addressed. The policy review form can be found here. (Google Form)
  7. C3LX tracks compliance with HIPAA and publishes results here. (https://c3lx.com/policies)

Additional documentation related to maintenance of policies is outlined in the Security officers responsibilities.

Risk Management Policy

This policy establishes the scope, objectives, and procedures of C3LX's information security risk management process. The risk management process is intended to support and protect the organization and its ability to fulfill its mission.

Applicable Standards from the HITRUST Common Security Framework

  • 03.a - Risk Management Program Development
  • 03.b - Performing Risk Assessments
  • 03.c - Risk Mitigation

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(1)(ii)(A) – HIPAA Security Rule Risk Analysis
  • 164.308(a)(1)(ii)(B) – HIPAA Security Rule Risk Management
  • 164.308(a)(8) – HIPAA Security Rule Evaluation

Risk Management Policies

  1. It is the policy of C3LX to conduct thorough and timely risk assessments of the potential threats and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI) (and other confidential and proprietary electronic information) it stores, transmits, and/or processes for its Customers and to develop strategies to efficiently and effectively mitigate the risks identified in the assessment process as an integral part of the C3LX's information security program.
  2. Risk analysis and risk management are recognized as important components of C3LX’s corporate compliance program and information security program in accordance with the Risk Analysis and Risk Management implementation specifications within the Security Management standard and the evaluation standards set forth in the HIPAA Security Rule, 45 CFR 164.308(a)(1)(ii)(A), 164.308(a)(1)(ii)(B), 164.308(a)(1)(i), and 164.308(a)(8).
    1. Risk assessments are done throughout product life cycles:
    2. Before the integration of new system technologies and before changes are made to C3LX’s physical safeguards; and
      • These changes do not include routine updates to existing systems, deployments of new systems created based on previously configured systems, deployments of new Customers, or new code developed for operations and management of the C3LX Platform.
    3. While making changes to C3LX physical equipment and facilities that introduce new, untested configurations.
    4. C3LX performs periodic technical and non-technical assessments of the security rule requirements as well as in response to environmental or operational changes affecting the security of ePHI.
  3. C3LX implements security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to:
    1. Ensure the confidentiality, integrity, and availability of all ePHI C3LX receives, maintains, processes, and/or transmits for its Customers;
    2. Protect against any reasonably anticipated threats or hazards to the security or integrity of Customer ePHI;
    3. Protect against any reasonably anticipated uses or disclosures of Customer ePHI that are not permitted or required; and
    4. Ensure compliance by all workforce members.
  4. Any risk remaining (residual) after other risk controls have been applied, requires sign off by the senior management and C3LX’s Security Officer.
  5. All C3LX workforce members are expected to fully cooperate with all persons charged with doing risk management work, including contractors and audit personnel. Any workforce member that violates this policy will be subject to disciplinary action based on the severity of the violation, as outlined in the C3LX Roles Policy.
  6. The implementation, execution, and maintenance of the information security risk analysis and risk management process is the responsibility of C3LX’s Security Officer (or other designated employee), and the identified Risk Management Team.
  7. All risk management efforts, including decisions made on what controls to put in place as well as those to not put into place, are documented and the documentation is maintained for six years.

Risk Management Procedures

Risk Assessment: The intent of completing a risk assessment is to determine potential threats and vulnerabilities and the likelihood and impact should they occur. The output of this process helps to identify appropriate controls for reducing or eliminating risk.

  • Step 1. System Characterization

    • The first step in assessing risk is to define the scope of the effort. To do this, identify where ePHI is received, maintained, processed, or transmitted. Using information-gathering techniques, the C3LX Platform boundaries are identified.
    • Output – Characterization of the C3LX Platform system assessed, a good picture of the Platform environment, and delineation of Platform boundaries.
  • Step 2. Threat Identification

    • Potential threats (the potential for threat-sources to successfully exercise a particular vulnerability) are identified and documented. All potential threat-sources through the review of historical incidents and data from intelligence agencies, the government, etc., to help generate a list of potential threats.
    • Output – A threat list containing a list of threat-sources that could exploit Platform vulnerabilities.
  • Step 3. Vulnerability Identification

    • Develop a list of technical and non-technical Platform vulnerabilities that could be exploited or triggered by potential threat-sources. Vulnerabilities can range from incomplete or conflicting policies that govern an organization’s computer usage to insufficient safeguards to protect facilities that house computer equipment to any number of software, hardware, or other deficiencies that comprise an organization’s computer network.
    • Output – A list of the Platform vulnerabilities (observations) that could be exercised by potential threat-sources.
  • Step 4. Control Analysis

    • Document and assess the effectiveness of technical and non-technical controls that have been or will be implemented by C3LX to minimize or eliminate the likelihood / probability of a threat-source exploiting a Platform vulnerability.
    • Output – List of current or planned controls (policies, procedures, training, technical mechanisms, insurance, etc.) used for the Platform to mitigate the likelihood of a vulnerability being exercised and reduce the impact of such an adverse event.
  • Step 5. Likelihood Determination

    • Determine the overall likelihood rating that indicates the probability that a vulnerability could be exploited by a threat-source given the existing or planned security controls.
    • Output – Likelihood rating of low (.1), medium (.5), or high (1). Refer to the NIST SP 800-30 definitions of low, medium, and high.
  • Step 6. Impact Analysis

    • Determine the level of adverse impact that would result from a threat successfully exploiting a vulnerability. Factors of the data and systems to consider should include the importance to C3LX's mission; sensitivity and criticality (value or importance); costs associated; loss of confidentiality, integrity, and availability of systems and data.
    • Output – Magnitude of impact rating of low (10), medium (50), or high (100). Refer to the NIST SP 800-30 definitions of low, medium, and high.
  • Step 7. Risk Determination

    • Establish a risk level. By multiplying the ratings from the likelihood determination and impact analysis, a risk level is determined. This represents the degree or level of risk to which an IT system, facility, or procedure might be exposed if a given vulnerability were exercised. The risk rating also presents actions that senior management must take for each risk level.
    • Output – Risk level of low (1-10), medium (>10-50) or high (>50-100). Refer to the NIST SP 800-30 definitions of low, medium, and high.
  • Step 8. Control Recommendations

    • Identify controls that could reduce or eliminate the identified risks, as appropriate to the organization’s operations to an acceptable level. Factors to consider when developing controls may include effectiveness of recommended options (i.e., system compatibility), legislation and regulation, organizational policy, operational impact, and safety and reliability. Control recommendations provide input to the risk mitigation process, during which the recommended procedural and technical security controls are evaluated, prioritized, and implemented.
    • Output – Recommendation of control(s) and alternative solutions to mitigate risk.
  • Step 9. Results Documentation

    • Results of the risk assessment are documented in an official report, spreadsheet, or briefing and provided to senior management to make decisions on policy, procedure, budget, and Platform operational and management changes.
    • Output – A risk assessment report that describes the threats and vulnerabilities, measures the risk, and provides recommendations for control implementation.

Risk Mitigation: Risk mitigation involves prioritizing, evaluating, and implementing the appropriate risk-reducing controls recommended from the Risk Assessment process to ensure the confidentiality, integrity and availability of C3LX Platform ePHI. Determination of appropriate controls to reduce risk is dependent upon the risk tolerance of the organization consistent with its goals and mission.

  • Step 1. Prioritize Actions

    • Using results from Step 7 of the Risk Assessment, sort the threat and vulnerability pairs according to their risk-levels in descending order. This establishes a prioritized list of actions needing to be taken, with the pairs at the top of the list getting/requiring the most immediate attention and top priority in allocating resources
    • Output – Actions ranked from high to low
  • Step 2. Evaluate Recommended Control Options

    • Although possible controls for each threat and vulnerability pair are arrived at in Step 8 of the Risk Assessment, review the recommended control(s) and alternative solutions for reasonableness and appropriateness. The feasibility (e.g., compatibility, user acceptance, etc.) and effectiveness (e.g., degree of protection and level of risk mitigation) of the recommended controls should be analyzed. In the end, select a “most appropriate” control option for each threat and vulnerability pair.
    • Output – list of feasible controls
  • Step 3. Conduct Cost-Benefit Analysis

    • Determine the extent to which a control is cost-effective. Compare the benefit (e.g., risk reduction) of applying a control with its subsequent cost of application. Controls that are not cost-effective are also identified during this step. Analyzing each control or set of controls in this manner, and prioritizing across all controls being considered, can greatly aid in the decision-making process.
    • Output – Documented cost-benefit analysis of either implementing or not implementing each specific control
  • Step 4. Select Control(s)

    • Taking into account the information and results from previous steps, C3LX’s mission, and other important criteria, the Risk Management Team determines the best control(s) for reducing risks to the information systems and to the confidentiality, integrity, and availability of ePHI. These controls may consist of a mix of administrative, physical, and/or technical safeguards.
    • Output – Selected control(s)
  • Step 5. Assign Responsibility

    • Identify the workforce members with the skills necessary to implement each of the specific controls outlined in the previous step, and assign their responsibilities. Also identify the equipment, training and other resources needed for the successful implementation of controls. Resources may include time, money, equipment, etc.
    • Output – List of resources, responsible persons and their assignments
  • Step 6. Develop Safeguard Implementation Plan

    • Develop an overall implementation or action plan and individual project plans needed to implement the safeguards and controls identified. The Implementation Plan should contain the following information:
      • Each risk or vulnerability/threat pair and risk level;
      • Prioritized actions;
      • The recommended feasible control(s) for each identified risk;
      • Required resources for implementation of selected controls;
      • Team member responsible for implementation of each control;
      • Start date for implementation
      • Target date for completion of implementation;
      • Maintenance requirements.
    • The overall implementation plan provides a broad overview of the safeguard implementation, identifying important milestones and timeframes, resource requirements (staff and other individuals’ time, budget, etc.), interrelationships between projects, and any other relevant information. Regular status reporting of the plan, along with key metrics and success indicators should be reported to C3LX Senior Management.
    • Individual project plans for safeguard implementation may be developed and contain detailed steps that resources assigned carry out to meet implementation timeframes and expectations. Additionally, consider including items in individual project plans such as a project scope, a list deliverables, key assumptions, objectives, task completion dates and project requirements.
    • Output – Safeguard Implementation Plan
  • Step 7. Implement Selected Controls

    • As controls are implemented, monitor the affected system(s) to verify that the implemented controls continue to meet expectations. Elimination of all risk is not practical. Depending on individual situations, implemented controls may lower a risk level but not completely eliminate the risk.
    • Continually and consistently communicate expectations to all Risk Management Team members, as well as senior management and other key people throughout the risk mitigation process. Identify when new risks are identified and when controls lower or offset risk rather than eliminate it.
    • Additional monitoring is especially crucial during times of major environmental changes, organizational or process changes, or major facilities changes.
    • If risk reduction expectations are not met, then repeat all or a part of the risk management process so that additional controls needed to lower risk to an acceptable level can be identified.
    • Output – Residual Risk documentation

Risk Management Schedule: The two principle components of the risk management process - risk assessment and risk mitigation - will be carried out according to the following schedule to ensure the continued adequacy and continuous improvement of C3LX’s information security program:

  • Scheduled Basis – an overall risk assessment of C3LX’s information system infrastructure will be conducted annually. The assessment process should be completed in a timely fashion so that risk mitigation strategies can be determined and included in the corporate budgeting process.
  • Throughout a System’s Development Life Cycle – from the time that a need for a new, untested configuration and/or application is identified through the time it is disposed of, ongoing assessments of the potential threats to a system and its vulnerabilities should be undertaken as a part of the maintenance of the system.
  • As Needed – the Security Officer (or other designated employee) or Risk Management Team may call for a full or partial risk assessment in response to changes in business strategies, information technology, information sensitivity, integrations, threats, legal liabilities, or other significant factors that affect C3LX’s Platform.

Process Documentation

Maintain documentation of all risk assessment, risk management, and risk mitigation efforts for a minimum of six years.

Roles Policy

C3LX has a Security Officer [164.308(a)(2)] and Privacy Officer [164.308(a)(2)] appointed to assist in maintaining and enforcing safeguards towards compliance. The responsibilities associated with these roles are outlined below.

Applicable Standards from the HITRUST Common Security Framework

  • 02.f - Disciplinary Process
  • 06.d - Data Protection and Privacy of Covered Information
  • 06.f - Prevention of Misuse of Information Assets
  • 06.g - Compliance with Security Policies and Standards

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(2) - Assigned Security Responsibility
  • 164.308(a)(5)(i) - Security Awareness and Training

Privacy Officer

The Privacy Officer is responsible for assisting with compliance and security training for workforce members, assuring organization remains in compliance with evolving compliance rules, and helping the Security Officer in his responsibilities.

  1. Provides annual training to all workforce members of established policies and procedures as necessary and appropriate to carry out their job functions, and documents the training provided.
  2. Assists in the administration and oversight of business associate agreements.
  3. Manage relationships with customers and partners as those relationships affect security and compliance of ePHI.
  4. Assist Security Officer as needed.

The current C3LX Privacy Officer is Andrew Richburg (andrewrichburg@c3lx.com).

Workforce Training Responsibilities

  1. The Privacy Officer facilitates the training of all workforce members as follows:
  1. New workforce members within their first month of employment;
  2. Existing workforce members annually;
  3. Existing workforce members whose functions are affected by a material change in the policies and procedures, within a month after the material change becomes effective;
  4. Existing workforce members as needed due to changes in security and risk posture of C3LX.
    1. The Security Officer or designee maintains documentation of the training session materials and attendees for a minimum of six years.
    2. The training session focuses on, but is not limited to, the following subjects defined in C3LX‘s security policies and procedures:
  1. HIPAA Privacy, Security, and Breach notification rules;
  2. HITRUST Common Security Framework;
  3. NIST Security Rules;
  4. Risk Management procedures and documentation;
  5. Auditing. C3LX may monitor access and activities of all users;
  6. Workstations may only be used to perform assigned job responsibilities;
  7. Users may not download software onto C3LX's workstations and/or systems without prior approval from the Security Officer;
  8. Users are required to report malicious software to the Security Officer immediately;
  9. Users are required to report unauthorized attempts, uses of, and theft of C3LX’s systems and/or workstations;
  10. Users are required to report unauthorized access to facilities
  11. Users are required to report noted log-in discrepancies (i.e. application states users last log-in was on a date user was on vacation;
  12. Users may not alter ePHI maintained in a database, unless authorized to do so by a C3LX Customer;
  13. Users are required to understand their role in C3LX’s contingency plan;
  14. Users may not share their user names nor passwords with anyone;
  15. Requirements for users to create and change passwords;
  16. Users must set all applications that contain or transmit ePHI to automatically log off after “X” minutes of inactivity;
  17. Supervisors are required to report terminations of workforce members and other outside users;
  18. Supervisors are required to report a change in a users title, role, department, and/or location;
  19. Procedures to backup ePHI;
  20. Procedures to move and record movement of hardware and electronic media containing ePHI;
  21. Procedures to dispose of discs, CDs, hard drives, and other media containing ePHI;
  22. Procedures to re-use electronic media containing ePHI;
  23. SSH key and sensitive document encryption procedures.

Security Officer

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 C3LX 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 C3LX Security Officer is Andrew Richburg (andrewrichburg@c3lx.com).

Organizational Responsibilities

The Security Officer, in collaboration with the Privacy Officer, is responsible for facilitating the development, implementation, and oversight of all activities pertaining to C3LX’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. 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 established 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. 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 C3LX 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.
  1. Promptly, properly, and consistently investigates and addresses reported violations and takes steps to prevent recurrence.
  2. Applies consistent and appropriate sanctions against workforce members who fail to comply with the security policies and procedures of C3LX.
  3. Mitigates, to the extent practicable, any harmful effect known to C3LX of a use or disclosure of ePHI in violation of C3LX’s policies and procedures, even if effect is the result of actions of C3LX business associates, customers, and/or partners.
    1. Reports security efforts and incidents to administration immediately upon discovery. Responsibilities in the case of a known ePHI breach are documented in the C3LX Breach Policy.
    2. 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:
  1. Latest malicious software or virus alerts;
  2. C3LX’s requirement to report unauthorized attempts to access ePHI;
  3. Changes in creating or changing passwords;
  4. Additional security-focused training is provided to all workforce members by the Security Officer. This training includes, but is not limited to:
  5. Data backup plans;
  6. System auditing procedures;
  7. Redundancy procedures;
  8. Contingency plans;
  9. Virus protection;
  10. Patch management;
  11. Media Disposal and/or Re-use;
  12. Documentation requirements.

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 C3LX’s systems, applications, servers, workstations, etc. that contain ePHI.

  1. Monitor workstations and applications for unauthorized use, tampering, and theft and report non-compliance according to the Security Incident Response policy.
  2. Assist the Security and Privacy Officers to ensure appropriate role-based access is provided to all users.
  3. Take all reasonable steps to hire, retain, and promote workforce members and provide access to users who comply with the Security regulation and C3LX’s security policies and procedures.

Sanctions of Workforce Responsibilities

All workforce members report non-compliance of C3LX’s policies and procedures to the Security Officer or other individual as assigned by the Security Officer. 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 C3LX’s security policies and procedures. The Security Officer may request the assistance from others.
  1. Complete an audit trail/log to identify and verify the violation and sequence of events.
  2. Interview any individual that may be aware of or involved in the incident.
  3. All individuals are required to cooperate with the investigation process and provide factual information to those conducting the investigation.
  4. Provide individuals suspected of non-compliance of the Security rule and/or C3LX’s policies and procedures the opportunity to explain their actions.
  5. The investigators thoroughly documents the investigation as the investigation occurs.
    1. 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.
  1. 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 C3LX.
    1. The Security Officer facilitates taking appropriate steps to prevent recurrence of the violation (when possible and feasible).
    2. In the case of an insider threat, the Security Officer and Privacy Officer are to setup a team to investigate and mitigate the risk of insider malicious activity. C3LX workforce members are encouraged to come forward with information about insider threats, and can do so anonymously.
    3. 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.

Data Management Policy

C3LX has procedures to create and maintain retrievable exact copies of electronic protected health information (ePHI) stored in conjunction with C3LX Apps and Tools. The policy and procedures will assure that complete, accurate, retrievable, and tested backups are available for all systems used by C3LX.

Data backup is an important part of the day-to-day operations of C3LX. To protect the confidentiality, integrity, and availability of ePHI, both for C3LX and C3LX Customers, complete backups are done daily to assure that data remains available when it needed and in case of disaster. Aptible manages data backups on behalf of C3LX.

Violation of this policy and its procedures by workforce members may result in corrective disciplinary action, up to and including termination of employment.

Applicable Standards from the HITRUST Common Security Framework

  • 01.v - Information Access Restriction

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(7)(ii)(A) - Data Backup Plan
  • 164.310(d)(2)(iii) - Accountability
  • 164.310(d)(2)(iv) - Data Backup and Storage

Backup Policy and Procedures

  1. Perform daily snapshot backups of all systems that process, store, or transmit ePHI for C3LX Customers.
  2. C3LX Ops Team, lead by the Engineering Lead, is designated to be in charge of backups.
  3. Dev Ops Team members are trained and assigned assigned to complete backups and manage the backup media.
  4. Document backups
    • Name of the system
    • Date & time of backup
    • Where backup stored (or to whom it was provided)
  5. Securely encrypt stored backups in a manner that protects them from loss or environmental damage.
  6. Test backups and document that files have been completely and accurately restored from the backup media.

System Access Policy

Access to C3LX systems and application is limited for all users, including but not limited to workforce members, volunteers, business associates, contracted providers, consultants, and any other entity, is allowable only on a minimum necessary basis. All users are responsible for reporting an incident of unauthorized user or access of the organization’s information systems. These safeguards have been established to address the HIPAA Security regulations including the following:

Applicable Standards from the HITRUST Common Security Framework

  • 01.d - User Password Management
  • 01.f - Password Use
  • 01.r - Password Management System
  • 01.a - Access Control Policy
  • 01.b - User Registration
  • 01.h - Clear Desk and Clear Screen Policy
  • 01.j - User Authentication for External Connections
  • 01.q - User Identification and Authentication
  • 01.v - Information Access Restriction
  • 02.i - Removal of Access Rights
  • 06.e - Prevention of Misuse of Information Assets

Applicable Standards from the HIPAA Security Rule

  • 164.308a4iiC Access Establishment and Modification
  • 164.308a3iiB Workforce Clearance Procedures
  • 164.308a4iiB Access Authorization
  • 164.312d Person or Entity Authentication
  • 164.312a2i Unique User Identification
  • 164.308a5iiD Password Management
  • 164.312a2iii Automatic Logoff
  • 164.310b Workstation Use
  • 164.310c Workstation Security
  • 164.308a3iiC Termination Procedures

Access Establishment and Modification

  • Requests for access to C3LX Platform systems and applications is made formally to the Lead Developer, Privacy Officer, or Security Officer.
  • Access is not granted until receipt, review, and approval by the C3LX Security Officer;
  • The request for access is retained for future reference.
  • All access to C3LX systems and services are reviewed and updated on an annual basis to assure proper authorizations are in place commensurate with job functions. The form used to conduct account review is here. (Google Form)
  • Any C3LX workforce member can request change of access using this form. (Google Form)
  • Access to systems is controlled using centralized user management and authentication. All authentication requests utilize two factor authentication using mobile devices as the second factor.
  • Temporary accounts are not used unless absolutely necessary for business purposes.
    • Accounts are reviewed every 90 days to assure temporary accounts are not left unnecessarily.
    • Accounts that are inactive for over 90 days are removed.
  • In the case of non-personal information, such as generic educational content, identification and authentication may not be required.
  • Privileged users must first access systems using standard, unique user accounts before switching to privileged users and performing privileged tasks.
  • All application to application communication using service accounts is restricted and not permitted unless absolutely needed. Automated tools are used to limit account access across applications and systems.
  • Generic accounts are not allowed on C3LX systems.
  • Access is granted through encrypted, VPN tunnels.
    • VPN utilizes AES 256 bit encryption.
  • In cases of increased risk or known attempted unauthorized access, immediate steps are taken by the Security and Privacy Officer to limit access and reduce risk of unauthorized access.
  • Direct system to system, system to application, and application to application authentication and authorization are limited and controlled to restrict access.

Workforce Clearance Procedures

  • The level of security assigned to a user to the organization’s information systems is based on the minimum necessary amount of data access required to carry out legitimate job responsibilities assigned to a user’s job classification and/or to a user needing access to carry out treatment, payment, or healthcare operations.
  • All access requests are treated on a ‘least-access principle”.
  • C3LX maintains a minimum necessary approach to access to Customer data. As such, C3LX, including all workforce members, does not readily have access to any ePHI.

Access Authorization

  • Role based access categories for each C3LX system and application are pre-approved by the Security Officer or Lead Developer.
  • C3LX utilizes hardware and software firewalls to segment data, prevent unauthorized access, and monitor traffic for denial of service attacks.

Person or Entity Authentication

  • Each workforce member has and uses a unique user ID and password that identifies him/her as the user of the information system.
  • Each Customer and Partner has and uses a unique user ID and password that identifies him/her as the user of the information system.

Unique User Identification

  • Access to the C3LX Platform systems and applications is controlled by requiring unique User Login ID’s and passwords for each individual user and developer.
  • Passwords requirements mandate strong password controls (see below).
  • Passwords are not displayed at any time and are not transmitted or stored in plain text.
  • Default accounts on all production systems, including root, are disabled.
  • Shared accounts are not allowed within C3LX systems or networks.

Automatic Logoff

  • Users are required to make information systems inaccessible by any other individual when unattended by the users (ex. by using a password protected screen saver or logging off the system).
  • Information systems automatically log users off the systems after 10 minutes of inactivity.
  • The Security Officer pre-approves exceptions to automatic log off requirements.

Employee Workstation Use

All workstations at C3LX are company owned, and all are laptop Apple products running Mac operating system.

  • Workstations may not be used to engage in any activity that is illegal or is in violation of organization’s policies.
  • Information systems/applications also may not be used for any other purpose that is illegal, unethical, or against company policies or contrary to organization’s best interests. Messages containing information related to a lawsuit or investigation may not be sent without prior approval.
  • Solicitation of non-company business, or any use of organization’s information systems/applications for personal gain is prohibited.
  • Users may not misrepresent, obscure, suppress, or replace another user’s identity in transmitted or stored messages.
  • Workstation hard drives will be encrypted using FileVault 2.0.
  • All workstations have firewalls enabled to prevent unauthorized access unless explicitly granted.
  • All workstations are to have the following messages added to the lock screen and login screen: This computer is owned by C3LX, Inc. By logging in, unlocking, and/or using this computer you acknowledge you have seen, and follow, these policies (https://c3lx.com/policies) and have completed this training (https://c3lx.com/training). Please contact us if you have problems with this - andrewrichburg@c3lx.com

Wireless Access Use

  • C3LX production systems are not accessible directly over wireless channels.
  • Wireless access disabled on all production systems.
  • When access production systems via remote wireless connections, the same system access policies and procedures apply to wireless as all other connections, including wired.
  • Wireless networks managed within C3LX non-production facilities (offices, etc) are secured with the following configurations:
    • All data in transit over wireless is encrypted using WPA2 encryption;
    • SSIDs are not broadcast;
    • Passwords are rotated on a regular basis, presently quarterly. This process is managed by the C3LX Security Officer.

Employee Termination Procedures

  • The Human Resources Department (or other designated department), users, and their supervisors are required to notify the Security Officer upon completion and/or termination of access needs and facilitating completion of the “Termination Checklist".
  • The Human Resources Department, users, and supervisors are required to terminate a user’s access rights if there is evidence or reason to believe the following (these incidents are also reported on an incident report and is filed with the Privacy Officer):
    • The user has been using their access rights inappropriately;
    • A user’s password has been compromised (a new password may be provided to the user if the user is not identified as the individual compromising the original password);
    • An unauthorized individual is utilizing a user’s User Login ID and password (a new password may be provided to the user if the user is not identified as providing the unauthorized individual with the User Login ID and password).
  • The Security Officer will terminate users’ access rights immediately upon notification.
  • The Security Officer audits and may terminate access of users that have not logged into organization’s information systems/applications for an extended period of time.

Paper Records

C3LX does not use paper records for any sensitive information. Use of paper for recording and storing sensitive data is against C3LX policies.

Password Management

  • User IDs and passwords are used to control access to C3LX systems and may not be disclosed to anyone for any reason.
  • Users may not allow anyone, for any reason, to have access to any information system using another user’s unique user ID and password.
  • On all production systems and application in the C3LX environment, password configurations are set to require that passwords are a minimum of 8 character length, 90 day password expiration, account lockout after 5 invalid attempts, password history of last 4 passwords remembered, and account lockout after 15 minutes of inactivity.
  • All system and application passwords are hashed by concatenating the user's password and a random 256-bit salt value, generated on a per-user basis, and then applying SHA-256 to the value to create a password hash using Argon2. The password hash and the salt are then stored in the backend database and are used for password validation on future user authentication attempts.
  • Each information system automatically requires users to change passwords at a pre-determined interval as determined by the organization, based on the criticality and sensitivity of the ePHI contained within the network, system, application, and/or database.
  • Passwords are inactivated immediately upon an employee’s termination (refer to the termination procedures in this policy).
  • All default system, application, and Partner passwords are changed before deployment to production.
  • Upon initial login, users must change any passwords that were automatically generated for them.
  • All passwords used in configuration scripts are secured and encrypted.
  • If a user believes their user ID has been compromised, they are required to immediately report the incident to the Security Office.

Client Access to Systems

C3LX grants Clients secure system access. This access is only to Client-specific systems, no other systems in the environment. These connections are setup at Client deployment. These connections are secured and encrypted and the only method for Clients to connect to C3LX hosted systems.

To support data analysis, C3LX does, on a case by case basis, support Clients in exporting deidentified patient data. In these cases C3LX supports SCP assuring all data is secured and encrypted in transit.

Auditing Policy

C3LX shall audit access and activity of electronic protected health information (ePHI) applications and systems in order to ensure compliance. The Security Rule requires healthcare organizations to implement reasonable hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ePHI. Audit activities may be limited by application, system, and/or network auditing capabilities and resources. C3LX shall make reasonable and good-faith efforts to safeguard information privacy and security through a well-thought-out approach to auditing that is consistent with available resources.

It is the policy of C3LX to safeguard the confidentiality, integrity, and availability of applications, systems, and networks. To ensure that appropriate safeguards are in place and effective, C3LX shall audit access and activity to detect, report, and guard against:

  • Network vulnerabilities and intrusions;
  • Breaches in confidentiality and security of patient protected health information;
  • Performance problems and flaws in applications;
  • Improper alteration or destruction of ePHI;
  • Out of date software and/or software known to have vulnerabilities.

This policy applies to all C3LX Platform systems, including BaaS, that store, transmit, or process ePHI.

Applicable Standards from the HITRUST Common Security Framework

  • 0.a Information Security Management Program
  • 01.a Access Control Policy
  • 01.b User Registration
  • 01.c Privilege Management
  • 09.aa Audit Logging
  • 09.ac Protection of Log Information
  • 09.ab - Monitoring System Use
  • 06.e - Prevention of Misuse of Information

Applicable Standards from the HIPAA Security Rule

  • 45 CFR ¬ß 164.308(a)(1)(ii)(D) - Information System Activity Review
  • 45 CFR ¬ß 164.308(a)(5)(ii)(B) & (C) - Protection from Malicious Software & Log-in Monitoring
  • 45 CFR ¬ß 164.308(a)(2) - HIPAA Security Rule Periodic Evaluation
  • 45 CFR ¬ß 164.312(b) - Audit Controls
  • 45 CFR ¬ß 164.312(c)(2) - Mechanism to Authenticate ePHI
  • 45 CFR ¬ß 164.312(e)(2)(i) - Integrity Controls

Auditing Policies

  1. Responsibility for auditing information system access and activity is assigned to C3LX’s Security Officer. The Security Officer shall:
    • Assign the task of generating reports for audit activities to the workforce member responsible for the application, system, or network;
    • Assign the task of reviewing the audit reports to the workforce member responsible for the application, system, or network, the Privacy Officer, or any other individual determined to be appropriate for the task;
    • Organize and provide oversight to a team structure charged with audit compliance activities (e.g., parameters, frequency, sample sizes, report formats, evaluation, follow-up, etc.).
    • All connections to C3LX are monitored. Access is limited to certain services, ports, and destinations. Exceptions to these rules, if created, are reviewed on an annual basis.
  2. C3LX’s auditing processes shall address access and activity at the following levels listed below. Auditing processes may address date and time of each log-on attempt, date and time of each log-off attempt, devices used, functions performed, etc.
    • User: User level audit trails generally monitor and log all commands directly initiated by the user, all identification and authentication attempts, and data and services accessed.
    • Application: Application level audit trails generally monitor and log all user activities, including data accessed and modified and specific actions.
    • System: System level audit trails generally monitor and log user activities, applications accessed, and other system defined specific actions. C3LX utilizes file system monitoring from Threat Stack, Inc. (“Threat Stack”) to assure the integrity of file system data.
    • Network: Network level audit trails generally monitor information on what is operating, penetrations, and vulnerabilities.
  3. C3LX shall log all incoming and outgoing traffic to into and out of its environment. This includes all successful and failed attempts at data access and editing. Data associated with this data will include origin, destination, time, and other relevant details that are available to C3LX.
  4. C3LX utilizes Threat Stack to scan all systems for malicious and unauthorized software continuously. Alerts from Threat Stack are sent to Papertrail, the centralized logging service that we use.
  5. C3LX leverages process monitoring tools throughout its environment.
  6. C3LX treats its Developer Portal as a Platform Add-on and, as such, it logs all activity associated with Developer Portal Access.
  7. C3LX uses Threat Stack to monitor the integrity of log files by utilizing Threat Stack System Integrity Checking capabilities.
  8. C3LX shall identify “trigger events” or criteria that raise awareness of questionable conditions of viewing of confidential information. The “events” may be applied to the entire C3LX Platform or may be specific to Apps, Tools, a Customer, partner, or business associate (See Listing of Potential Trigger Events below).
  9. In addition to trigger events, C3LX utilizes Threat Stack's log correlation functionality to proactively identify and enable alerts based on log data.
  10. Logs are reviewed monthly by the Security Officer.
  11. C3LX’s Security Officer and Privacy Officer are authorized to select and use auditing tools that are designed to detect network vulnerabilities and intrusions. Such tools are explicitly prohibited by others, including Customers and Partners, without the explicit authorization of the Security Officer. These tools may include, but are not limited to:
    • Scanning tools and devices;
    • Password cracking utilities;
    • Network “sniffers.”
    • Passive and active intrusion detection systems.
  12. The process for review of audit logs, trails, and reports shall include:
    • Description of the activity as well as rationale for performing the audit.
    • Identification of which C3LX workforce members will be responsible for review (workforce members shall not review audit logs that pertain to their own system activity).
    • Frequency of the auditing process.
    • Determination of significant events requiring further review and follow-up.
    • Identification of appropriate reporting channels for audit results and required follow-up.
  13. Vulnerability testing software may be used to probe the network to identify what is running (e.g., operating system or product versions in place), whether publicly-known vulnerabilities have been corrected, and evaluate whether the system can withstand attacks aimed at circumventing security controls.
    • Testing may be carried out internally or provided through an external third-party vendor. Whenever possible, a third party auditing vendor should not be providing the organization IT oversight services (e.g., vendors providing IT services should not be auditing their own services - separation of duties).
    • Testing shall be done on a routine basis, currently monthly.
  14. Software patches and updates will be applied to all systems in a timely manner. In the case of routine updates, they will be applied after thorough testing. In the case of updates to correct known vulnerabilities, priority will be given to testing to speed the time to production. Critical security patches are applied within 30 days from testing and all security patches are applied within 90 days after testing.

Audit Requests

  1. A request may be made for an audit for a specific cause. The request may come from a variety of sources including, but not limited to, Privacy Officer, Security Officer, Customer, or Partner.
  2. A request for an audit for specific cause must include time frame, frequency, and nature of the request. The request must be reviewed and approved by C3LX’s Privacy or Security Officer.
  3. A request for an audit must be approved by C3LX’s Privacy Officer and/or Security Officer before proceeding. Under no circumstances shall detailed audit information be shared with parties without proper permissions and access to see such data.
    • Should the audit disclose that a workforce member has accessed ePHI inappropriately, the minimum necessary/least privileged information shall be shared with C3LX’s Security Officer to determine appropriate sanction/corrective disciplinary action.
    • Only de-identified information shall be shared with a Customer or Partner regarding the results of the investigative audit process. This information will be communicated to the appropriate personnel by C3LX’s Privacy Officer or designee. Prior to communicating with Customers and Partners regarding an audit, it is recommended that C3LX consider seeking risk management and/or legal counsel.

Review and Reporting of Audit Findings

  1. Audit information that is routinely gathered must be reviewed in a timely manner, currently quarterly, by the responsible workforce member(s).
    • On a quarterly basis, logs are reviewed to assure the proper data is being captured and retained.
  2. The reporting process shall allow for meaningful communication of the audit findings to those workforce members, Customers, or Partners requesting the audit.
    • Significant findings shall be reported immediately in a written format. C3LX’s security incident response form may be utilized to report a single event.
    • Routine findings shall be reported to the sponsoring leadership structure in a written report format.
  3. Reports of audit results shall be limited to internal use on a minimum necessary/need-to-know basis. Audit results shall not be disclosed externally without administrative and/or legal counsel approval.
  4. Security audits constitute an internal, confidential monitoring practice that may be included in C3LX’s performance improvement activities and reporting. Care shall be taken to ensure that the results of the audits are disclosed to administrative level oversight structures only and that information which may further expose organizational risk is shared with extreme caution. Generic security audit information may be included in organizational reports (individually-identifiable ePHI shall not be included in the reports).
    5.4 Whenever indicated through evaluation and reporting, appropriate corrective actions must be undertaken. These actions shall be documented and shared with the responsible workforce members, Customers, and/or Partners.

Auditing Customer and Partner Activity

  1. Periodic monitoring of Customer and Partner activity shall be carried out to ensure that access and activity is appropriate for privileges granted and necessary to the arrangement between C3LX and the 3rd party. C3LX will make every effort to assure Customers and Partners do not gain access to data outside of their own environments.
  2. If it is determined that the Customer or Partner has exceeded the scope of access privileges, C3LX’s leadership must remedy the problem immediately.
  3. If it is determined that a Customer or Partner has violated the terms of the HIPAA business associate agreement or any terms within the HIPAA regulations, C3LX must take immediate action to remediate the situation. Continued violations may result in discontinuation of the business relationship.

Audit Log Security Controls and Backup

  1. Audit logs shall be protected from unauthorized access or modification, so the information they contain will be made available only if needed to evaluate a security incident or for routine audit activities as outlined in this policy.
  2. All audit logs are encrypted in transit and at rest to control access to the content of the logs.
  3. Audit logs shall be stored on a separate system to minimize the impact auditing may have on the privacy system and to prevent access to audit trails by those with system administrator privileges. This is done to apply the security principle of “separation of duties” to protect audit trails from hackers.

Workforce Training, Education, Awareness and Responsibilities

  1. C3LX workforce members are provided training, education, and awareness on safeguarding the privacy and security of business and ePHI. C3LX’s commitment to auditing access and activity of the information applications, systems, and networks is communicated through new employee orientation, ongoing training opportunities and events, and applicable policies. C3LX workforce members are made aware of responsibilities with regard to privacy and security of information as well as applicable sanctions/corrective disciplinary actions should the auditing process detect a workforce member’s failure to comply with organizational policies.
  2. C3LX Customers are provided with necessary information to understand C3LX auditing capabilities.

External Audits of Information Access and Activity

  1. Prior to contracting with an external audit firm, C3LX shall:
    • Outline the audit responsibility, authority, and accountability;
    • Choose an audit firm that is independent of other organizational operations;
    • Ensure technical competence of the audit firm staff;
    • Require the audit firm’s adherence to applicable codes of professional ethics;
    • Obtain a signed HIPAA business associate agreement;
    • Assign organizational responsibility for supervision of the external audit firm.

Retention of Audit Data

  1. Audit logs shall be maintained based on organizational needs. There is no standard or law addressing the retention of audit log/trail information. Retention of this information shall be based on:
    A. Organizational history and experience.
    B. Available storage space.
  2. Reports summarizing audit activities shall be retained for a period of six years.
  3. Log data is currently retained and readily accessible for a 1-month period via Papertrail, Inc (“Papertrail”). Beyond that, log data is available via cold backup via Amazon Glacier.

Potential Trigger Events

  • High risk or problem prone incidents or events.
  • Business associate, customer, or partner complaints.
  • Known security vulnerabilities.
  • Atypical patterns of activity.
  • Failed authentication attempts.
  • Remote access use and activity.
  • Activity post termination.
  • Random audits.

Configuration Management Policy

C3LX standardizes and automates configuration management through the use of Salt scripts as well as documentation of all changes to production systems and networks. Salt automatically configures all C3LX systems according to established and tested policies, and is used as part of our Disaster Recovery plan and process.

Applicable Standards from the HITRUST Common Security Framework

  • 06 - Configuration Management

Applicable Standards from the HIPAA Security Rule

  • 164.310(a)(2)(iii) Access Control & Validation Procedures

Configuration Management

  1. Salt is used to standardize and automate configuration management.
  2. Threatstack is used to scan systems every 2 hours and on reboot. These scans capture file system changes and also unauthorized or malicious software.
  3. No systems are deployed into C3LX environments without approval of the C3LX Lead Developer.
  4. All changes to production systems, network devices, and firewalls are approved by the C3LX Lead Developer before they are implemented to assure they comply with business and security requirements. Additionally, all changes are tested before they are implemented in production. All changes are documented using Google forms. Implementation of approved changes are only performed by authorized personnel.
  5. An up-to-date inventory of systems is maintained using Google spreadsheets and architecture diagrams hosted on Google Apps and Box. All systems are categorized as production and utility to differentiate based on criticality.
  6. Clocks are synchronized across all systems using NTP. Modifying time data on systems is restricted.
  7. All front end functionality (developer dashboards and portals) is separated from backend (database and app servers) systems by being deployed on separate servers.
  8. All software and systems are tested using unit tests and end to end tests.
  9. All committed code is reviewed using pull requests (on Github) to assure software code quality and proactively detect potential security issues in development.
  10. C3LX utilizes development and staging environments that mirror production to assure proper function.
  11. C3LX also deploys environments locally to assure functionality before moving to staging or production.
  12. C3LX schedules production deployments every four weeks.
  13. All formal change requests require unique ID and authentication.
  14. ClamAV is run on all production hosts for anti-virus protection. Hosts are scanned daily for malicious binaries in critical system paths. The malware signature database is checked hourly and automatically updated if new signatures are available. ClamAV is a part of our Salt-based configuration management and this assures all hosts have anti-virus tools running on them.
  15. All physical media is encrypted at provisioning. To verify encryption is consistent and in place for all production storage, checks are performed on a quarterly basis.

Facility Access Policy

C3LX works with Partners to assure restriction of physical access to systems used as part of the C3LX Platform. C3LX and its Partners control access to the physical buildings/facilities that house these systems/applications, or in which C3LX workforce members operate, in accordance to the HIPAA Security Rule 164.310 and its implementation specifications. Physical Access to all of C3LX facilities is limited to only those authorized in this policy. In an effort to safeguard ePHi from unauthorized access, tampering, and theft, access is allowed to areas only to those persons authorized to be in them and with escorts for unauthorized persons. All workforce members are responsible for reporting an incident of unauthorized visitor and/or unauthorized access to C3LX’s facility.

Of note, C3LX does not have ready access to ePHI. C3LX does not physically house any systems used by its Platform in C3LX facilities. Physical security of our Platform servers is managed by our Partner, Aptible.

Applicable Standards from the HITRUST Common Security Framework

  • 08.b - Physical Entry Controls
  • 08.d - Protecting Against External and Environmental Threats
  • 08.j - Equipment Maintenance
  • 08.l - Secure Disposal or Re-Use of Equipment
  • 09.p - Disposal of Media

Applicable Standards from the HIPAA Security Rule

  • 164.310(a)(2)(ii) Facility Security Plan
  • 164.310(a)(2)(iii) Access Control & Validation Procedures
  • 164.310(b-c) Workstation Use & Security

C3LX-controlled Facility Access Policies

  1. Visitor and third party support access is recorded and supervised. All visitors are escorted.
  2. Repairs are documented and the documentation is retained.
  3. Fire extinguishers and detectors are installed according to applicable laws and regulations.
  4. Maintenance is controlled and conducted by authorized personnel in accordance with supplier-recommended intervals, insurance policies and the organizations maintenance program.
  5. Electronic and physical media containing covered information is securely destroyed (or the information securely removed) prior to disposal.
  6. The organization securely disposes media with sensitive information.
  7. Physical access is restricted using smart locks that track all access.
    • Restricted areas and facilities are locked and when unattended (where feasible).
    • Only authorized workforce members receive access to restricted areas (as determined by the Security Officer).
    • Access and keys are revoked upon termination of workforce members.
    • Workforce members must report a lost and/or stolen key(s) to the Security Officer.
    • The Security Officer facilitates the changing of the lock(s) within 7 days of a key being reported lost/stolen
  8. Enforcement of Facility Access Policies
    • Report violations of this policy to the restricted area’s department team leader, supervisor, manager, or director, or the Privacy Officer.
    • Workforce members in violation of this policy are subject to disciplinary action, up to and including termination.
    • Visitors in violation of this policy are subject to loss of vendor privileges and/or termination of services from C3LX.
  9. Workstation Security
    • Workstations may only be accessed and utilized by authorized workforce members to complete assigned job/contract responsibilities.
    • All workforce members are required to monitor workstations and report unauthorized users and/or unauthorized attempts to access systems/applications as per the System Access Policy.
    • All workstations purchased by C3LX are the property of C3LX and are distributed to users by the company.

Incident Response Policy

C3LX implements an information security incident response process to consistently detect, respond, and report incidents, minimize loss and destruction, mitigate the weaknesses that were exploited, and restore information system functionality and business continuity as soon as possible.

The incident response process addresses:

  • Continuous monitoring of threats through intrusion detection systems (IDS) and other monitoring applications;
  • Establishment of an information security incident response team;
  • Establishment of procedures to respond to media inquiries;
  • Establishment of clear procedures for identifying, responding, assessing, analyzing, and follow-up of information security incidents;
  • Workforce training, education, and awareness on information security incidents and required responses; and
  • Facilitation of clear communication of information security incidents with internal, as well as external, stakeholders

Applicable Standards from the HITRUST Common Security Framework

  • 11.a - Reporting Information Security Events
  • 11.c - Responsibilities and Procedures
  • 11.a - Reporting Information Security Events

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(5)(i) – Security Awareness and Training
  • 164.308(a)(6) – Security Incident Procedures

Incident Management Policies

The C3LX incident response process follows the process recommended by SANS, an industry leader in security (www.sans.org).

Identification Phase

  1. Immediately upon observation C3LX members report suspected and known Precursors, Events, Indications, and Incidents in one of the following ways:
    1. Direct report to management, the Security Officer, Privacy Officer, or other;
    2. Email;
    3. Phone call;
    4. Online incident response form located here; (google form)
    5. Secure Chat.
    6. Anonymously through workforce members desired channels.
    7. The individual receiving the report facilitates completion of an Incident Identification form and notifies the Security Officer (if not already done).
    8. The Security Officer determines if the issue is a Precursor, Event, Indication, or Incident.
    9. If the issue is an event, indication, or precursor the Security Officer forwards it to the appropriate resource for resolution.
      1. Non-Technical Event (minor infringement): the Security Officer completes a SIR Form (see Appendix 2) and investigates the incident.
      2. Technical Event: Assign the issue to an IT resource for resolution. This resource may also be a contractor or outsourced technical resource, in the event of a small office or lack of expertise in the area.
    10. If the issue is a security incident the Security Officer activates the Security Incident Response Team (SIRT) and notifies senior management.
      1. If a non-technical security incident is discovered the SIRT completes the investigation, implements preventative measures, and resolves the security incident.
      2. Once the investigation is completed, progress to Phase V, Follow-up.
      3. If the issue is a technical security incident, commence to Phase II: Containment.
      4. The Containment, Eradication, and Recovery Phases are highly technical. It is important to have them completed by a highly qualified technical security resource with oversight by the SIRT team.
      5. Each individual on the SIRT and the technical security resource document all measures taken during each phase, including the start and end times of all efforts.
      6. The lead member of the SIRT team facilitates initiation of a Security Incident Report (SIR) Form (See Appendix 2 for sample format) or an Incident Survey Form (See Appendix 4). The intent of the SIR form is to provide a summary of all events, efforts, and conclusions of each Phase of this policy and procedures.
    11. The Security Officer, Privacy Officer, or C3LX representative appointed notifies any affected Customers and Partners. If no Customers and Partners are affected, notification is at the discretion of the Security and Privacy Officer.
    12. In the case of a threat identified, the Security Officer is to form a team to investigate and involve necessary resources, both internal to C3LX and potentially external.

Containment Phase (Technical)

In this Phase, C3LX attempts to contain the security incident. It is extremely important to take detailed notes during the security incident response process. This provides that the evidence gathered during the security incident can be used successfully during prosecution, if appropriate.

  1. The SIRT reviews any information that has been collected by the Security Officer or any other individual investigating the security incident.
  2. The SIRT secures the network perimeter.
  3. The engineering team performs the following:
    1. Securely connect to the affected system over a trusted connection.
    2. Retrieve any volatile data from the affected system.
    3. Determine the relative integrity and the appropriateness of backing the system up.
    4. If appropriate, back up the system.
    5. Change the password(s) to the affected system(s).
    6. Determine whether it is safe to continue operations with the affect system(s).
    7. If it is safe, allow the system to continue to function;
      1. Complete any documentation relative to the security incident on the SIR Form.
      2. Move to Phase V, Follow-up.
    8. If it is NOT safe to allow the system to continue operations, discontinue the system(s) operation and move to Phase III, Eradication.
    9. The individual completing this phase provides written communication to the SIRT.
  4. Continuously apprise Senior Management of progress.
  5. Continue to notify affected Customers and Partners with relevant updates as needed

Eradication Phase (Technical)

The Eradication Phase represents the SIRT’s effort to remove the cause, and the resulting security exposures, that are now on the affected system(s).

  1. Determine symptoms and cause related to the affected system(s).
  2. Strengthen the defenses surrounding the affected system(s), where possible (a risk assessment may be needed and can be determined by the Security Officer). This may include the following:
    1. An increase in network perimeter defenses.
    2. An increase in system monitoring defenses.
    3. Remediation (“fixing”) any security issues within the affected system, such as removing unused services/general host hardening techniques.
  3. Conduct a detailed vulnerability assessment to verify all the holes/gaps that can be exploited have been addressed.
    1. If additional issues or symptoms are identified, take appropriate preventative measures to eliminate or minimize potential future compromises.
  4. Complete the Eradication Form (see Appendix 4).
  5. Update the documentation with the information learned from the vulnerability assessment, including the cause, symptoms, and the method used to fix the problem with the affected system(s).
  6. Apprise Senior Management of the progress.
  7. Continue to notify affected Customers and Partners with relevant updates as needed.
  8. Move to Phase IV, Recovery.

Recovery Phase (Technical)

The Recovery Phase represents the SIRT’s effort to restore the affected system(s) back to operation after the resulting security exposures, if any, have been corrected.

  1. The technical team determines if the affected system(s) have been changed in any way.
    1. If they have, the technical team restores the system to its proper, intended functioning (“last known good”).
    2. Once restored, the team validates that the system functions the way it was intended/had functioned in the past. This may require the involvement of the business unit that owns the affected system(s).
    3. If operation of the system(s) had been interrupted (i.e., the system(s) had been taken offline or dropped from the network while triaged), restart the restored and validated system(s) and monitor for behavior.
    4. If the system had not been changed in any way, but was taken offline (i.e., operations had been interrupted), restart the system and monitor for proper behavior.
    5. Update the documentation with the detail that was determined during this phase.
    6. Apprise Senior Management of progress.
    7. Continue to notify affected Customers and Partners with relevant updates as needed.
    8. Move to Phase V, Follow-up.

Follow-up Phase (Technical and Non-Technical)

The Follow-up Phase represents the review of the security incident to look for “lessons learned” and to determine whether the process that was taken could have been improved in any way. It is recommended all security incidents be reviewed shortly after resolution to determine where response could be improved. Timeframes may extend to one to two weeks post-incident.

  1. Responders to the security incident (SIRT Team and technical security resource) meet to review the documentation collected during the security incident.
  2. Create a “lessons learned” document and attach it to the completed SIR Form.
    1. Evaluate the cost and impact of the security incident to C3LX using the documents provided by the SIRT and the technical security resource.
    2. Determine what could be improved.
    3. Communicate these findings to Senior Management for approval and for implementation of any recommendations made post-review of the security incident.
    4. Carry out recommendations approved by Senior Management; sufficient budget, time and resources should be committed to this activity.
    5. Close the security incident.

Periodic Evaluation

It is important to note that the processes surrounding security incident response should be periodically reviewed and evaluated for effectiveness. This also involves appropriate training of resources expected to respond to security incidents, as well as the training of the general population regarding the C3LX’s expectation for them, relative to security responsibilities. The incident response plan is tested annually.

Security Incident Response Team (SIRT)

Individuals needed and responsible to respond to a security incident make up a Security Incident Response Team (SIRT). Members may include the following:

  • Security Officer
  • Privacy Officer
  • Senior Management
  • Engineering Lead

Breach Policy

To provide guidance for breach notification when impressive or unauthorized access, acquisition, use and/or disclosure of the ePHI occurs. Breach notification will be carried out in compliance with the American Recovery and Reinvestment Act (ARRA)/Health Information Technology for Economic and Clinical Health Act (HITECH) as well as any other federal or state notification law.

The Federal Trade Commission (FTC) has published breach notification rules for vendors of personal health records as required by ARRA/HITECH. The FTC rule applies to entities not covered by HIPAA, primarily vendors of personal health records. The rule is effective September 24, 2009 with full compliance required by February 22, 2010.

The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, 2009. Title XIII of ARRA is the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH significantly impacts the Health Insurance Portability and Accountability (HIPAA) Privacy and Security Rules. While HIPAA did not require notification when patient protected health information (PHI) was inappropriately disclosed, covered entities and business associates may have chosen to include notification as part of the mitigation process. HITECH does require notification of certain breaches of unsecured PHI to the following: individuals, Department of Health and Human Services (HHS), and the media. The effective implementation for this provision is September 23, 2009 (pending publication HHS regulations).

In the case of a breach, C3LX shall notify all affected Clients. It is the responsibility of the Client to notify affected individuals. C3LX shall notify all affected Users who are not associated with Clients.

Applicable Standards from the HITRUST Common Security Framework

  • 11.a Reporting Information Security Events
  • 11.c Responsibilities and Procedures

Applicable Standards from the HIPAA Security Rule

  • Security Incident Procedures - 164.308(a)(6)(i)
  • HITECH Notification in the Case of Breach - 13402(a) and 13402(b)
  • HITECH Timeliness of Notification - 13402(d)(1)
  • HITECH Content of Notification - 13402(f)(1)

C3LX Breach Policy

  1. Discovery of Breach: A breach of ePHI shall be treated as “discovered” as of the first day on which such breach is known to the organization, or, by exercising reasonable diligence would have been known to C3LX (includes breaches by the organization’s Customers, Partners, or subcontractors). C3LX shall be deemed to have knowledge of a breach if such breach is known or by exercising reasonable diligence would have been known, to any person, other than the person committing the breach, who is a workforce member or Partner of the organization. Following the discovery of a potential breach, the organization shall begin an investigation (see organizational policies for security incident response and/or risk management incident response) immediately, conduct a risk assessment, and based on the results of the risk assessment, begin the process to notify each Customer affected by the breach. C3LX shall also begin the process of determining what external notifications are required or should be made (e.g., Secretary of Department of Health & Human Services (HHS), media outlets, law enforcement officials, etc.)
  2. Breach Investigation: The C3LX Security Officer shall name an individual to act as the investigator of the breach (e.g., privacy officer, security officer, risk manager, etc.). The investigator shall be responsible for the management of the breach investigation, completion of a risk assessment, and coordinating with others in the organization as appropriate (e.g., administration, security incident response team, human resources, risk management, public relations, legal counsel, etc.) The investigator shall be the key facilitator for all breach notification processes to the appropriate entities (e.g., HHS, media, law enforcement officials, etc.). All documentation related to the breach investigation, including the risk assessment, shall be retained for a minimum of six years. A template breach log is located here.
  3. Risk Assessment: For an acquisition, access, use or disclosure of ePHI to constitute a breach, it must constitute a violation of the HIPAA Privacy Rule. A use or disclosure of ePHI that is incident to an otherwise permissible use or disclosure and occurs despite reasonable safeguards and proper minimum necessary procedures would not be a violation of the Privacy Rule and would not qualify as a potential breach. To determine if an impermissible use or disclosure of ePHI constitutes a breach and requires further notification, the organization will need to perform a risk assessment to determine if there is significant risk of harm to the individual as a result of the impermissible use or disclosure. The organization shall document the risk assessment as part of the investigation in the incident report form noting the outcome of the risk assessment process. The organization has the burden of proof for demonstrating that all notifications to appropriate Customers or that the use or disclosure did not constitute a breach. Based on the outcome of the risk assessment, the organization will determine the need to move forward with breach notification. The risk assessment and the supporting documentation shall be fact specific and address:
    • Consideration of who impermissibly used or to whom the information was impermissibly disclosed;
    • The type and amount of ePHI involved;
    • The cause of the breach, and the entity responsible for the breach, either Customer, C3LX, or Partner.
    • The potential for significant risk of financial, reputational, or other harm.
  4. Timeliness of Notification: Upon discovery of a breach, notice shall be made to the affected C3LX Customers no later than 16 hours after the discovery of the breach. It is the responsibility of the organization to demonstrate that all notifications were made as required, including evidence demonstrating the necessity of delay.
  5. Delay of Notification Authorized for Law Enforcement Purposes: If a law enforcement official states to the organization that a notification, notice, or posting would impede a criminal investigation or cause damage to national security, the organization shall:
    • If the statement is in writing and specifies the time for which a delay is required, delay such notification, notice, or posting of the timer period specified by the official; or
    • If the statement is made orally, document the statement, including the identify of the official making the statement, and delay the notification, notice, or posting temporarily and no longer than 30 days from the date of the oral statement, unless a written statement as described above is submitted during that time.
  6. Content of the Notice: The notice shall be written in plain language and must contain the following information:
    • A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known;
    • A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known;
    • Any steps the Customer should take to protect Customer data from potential harm resulting from the breach.
    • A brief description of what C3LX is doing to investigate the breach, to mitigate harm to individuals and Customers, and to protect against further breaches.
    • Contact procedures for individuals to ask questions or learn additional information, which may include a toll-free telephone number, an e-mail address, a web site, or postal address.
  7. Methods of Notification: C3LX Customers will be notified via email and phone within the timeframe for reporting breaches, as outlined above.
  8. Maintenance of Breach Information/Log: As described above and in addition to the reports created for each incident, C3LX shall maintain a process to record or log all breaches of unsecured ePHI regardless of the number of records and Customers affected. The following information should be collected/logged for each breach (see sample Breach Notification Log):
    • A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
    • A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
    • A description of the action taken with regard to notification of patients regarding the breach.
    • Resolution steps taken to mitigate the breach and prevent future occurrences.
  9. Workforce Training: C3LX shall train all members of its workforce on the policies and procedures with respect to ePHI as necessary and appropriate for the members to carry out their job responsibilities. Workforce members shall also be trained as to how to identify and report breaches within the organization.
  10. Complaints: C3LX must provide a process for individuals to make complaints concerning the organization’s patient privacy policies and procedures or its compliance with such policies and procedures.
  11. Sanctions: The organization shall have in place and apply appropriate sanctions against members of its workforce, Customers, and Partners who fail to comply with privacy policies and procedures.
  12. Retaliation/Waiver: C3LX may not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against any individual for the exercise by the individual of any privacy right. The organization may not require individuals to waive their privacy rights under as a condition of the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits.

Sample Letter to Customers in Case of Breach

[Date]

[Name here]
[Address 1 Here]
[Address 2 Here]
[City, State Zip Code]

Dear [Name of Customer]:

I am writing to you from C3LX, Inc. with important information about a recent breach that affects your account with us. We became aware of this breach on [Insert Date] which occurred on or about [Insert Date]. The breach occurred as follows:

Describe event and include the following information: A. A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known. B. A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known. C. Any steps the Customer should take to protect themselves from potential harm resulting from the breach. D. A brief description of what C3LX is doing to investigate the breach, to mitigate harm to individuals, and to protect against further breaches. E. Contact procedures for individuals to ask questions or learn additional information, which includes a toll-free telephone number, an e-mail address, web site, or postal address.

Other Optional Considerations:

  • Recommendations to assist customer in remedying the breach.

We will assist you in remedying the situation.

Sincerely,

Andrew Richburg
CEO & Founder - C3LX, Inc
andrewrichburg@c3lx.com
303-870-5693

Disaster Recovery Policy

The C3LX Contingency Plan establishes procedures to recover C3LX following a disruption resulting from a disaster. This Disaster Recovery Policy is maintained by the C3LX Security Officer and Privacy Officer. Aptible automates many of the processes outlined on behalf of C3LX.

The following objectives have been established for this plan:

  1. Maximize the effectiveness of contingency operations through an established plan that consists of the following phases:
    • Notification/Activation phase to detect and assess damage and to activate the plan;
    • Recovery phase to restore temporary operations and recover damage done to the original system;
    • Reconstitution phase to restore system processing capabilities to normal operations.
  2. Identify the activities, resources, and procedures needed to carry out C3LX processing requirements during prolonged interruptions to normal operations.
  3. Identify and define the impact of interruptions to C3LX systems.
  4. Assign responsibilities to designated personnel and provide guidance for recovering C3LX during prolonged periods of interruption to normal operations.
  5. Ensure coordination with other C3LX staff who will participate in the contingency planning strategies.
  6. Ensure coordination with external points of contact and vendors who will participate in the contingency planning strategies.

This C3LX Contingency Plan has been developed as required under the Office of Management and Budget (OMB) Circular A-130, Management of Federal Information Resources, Appendix III, November 2000, and the Health Insurance Portability and Accountability Act (HIPAA) Final Security Rule, Section §164.308(a)(7), which requires the establishment and implementation of procedures for responding to events that damage systems containing electronic protected health information.

This C3LX Contingency Plan is created under the legislative requirements set forth in the Federal Information Security Management Act (FISMA) of 2002 and the guidelines established by the National Institute of Standards and Technology (NIST) Special Publication (SP) 800-34, titled "Contingency Planning Guide for Information Technology Systems" dated June 2002.

The C3LX Contingency Plan also complies with the following federal and departmental policies:

  • The Computer Security Act of 1987;
  • OMB Circular A-130, Management of Federal Information Resources, Appendix III, November 2000;
  • Federal Preparedness Circular (FPC) 65, Federal Executive Branch Continuity of Operations, July 1999;
  • Presidential Decision Directive (PDD) 67, Enduring Constitutional Government and Continuity of Government Operations, October 1998;
  • PDD 63, Critical Infrastructure Protection, May 1998;
  • Federal Emergency Management Agency (FEMA), The Federal Response Plan (FRP), April 1999;
  • Defense Authorization Act (Public Law 106-398), Title X, Subtitle G, “Government Information Security Reform,” October 30, 2000

Example of the types of disasters that would initiate this plan are natural disaster, political disturbances, man made disaster, external human threats, internal malicious activities.

C3LX defined two categories of systems from a disaster recovery perspective.

  1. Critical Systems. These systems host application servers and database servers or are required for functioning of systems that host application servers and database servers. These systems, if unavailable, affect the integrity of data and must be restored, or have a process begun to restore them, immediately upon becoming unavailable.
  2. Non-critical Systems. These are all systems not considered critical by definition above. These systems, while they may affect the performance and overall security of critical systems, do not prevent Critical systems from functioning and being accessed appropriately. These systems are restored at a lower priority than critical systems.

Applicable Standards from the HITRUST Common Security Framework

  • 12.c - Developing and Implementing Continuity Plans Including Information Security

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(7)(i) - Contingency Plan

Line of Succession

The following order of succession to ensure that decision-making authority for the C3LX Contingency Plan is uninterrupted. The Engineering Lead and Security Officer, are responsible for ensuring the safety of personnel and the execution of procedures documented within this C3LX Contingency Plan. If the Engineering Lead is unable to function as the overall authority or chooses to delegate this responsibility to a successor, the CEO shall function as that authority. To provide contact initiation should the contingency plan need to be initiated, please use the contact list below.

  • Andrew Richburg, CEO: 303-870-5693, andrewrichburg@c3lx.com
  • Angela Richburg, Lead Health Coach: angelarichburg@c3lx.com

Responsibilities

The following teams have been developed and trained to respond to a contingency event affecting the IT system.

  1. The Ops Team is responsible for recovery of the C3LX hosted environment, network devices, and all servers. Members of the team include personnel who are also responsible for the daily operations and maintenance of C3LX. The team leader is the Engineering Lead and directs the Dev Ops Team.
  2. The Web Services Team is responsible for assuring all application servers and web services are working. It is also responsible for testing redeployments and assessing damage to the environment. The team leader is the Engineering Lead and directs the Web Services Team.

Testing and Maintenance

The Engineering Lead shall establish criteria for validation/testing of a Contingency Plan, an annual test schedule, and ensure implementation of the test. This process will also serve as training for personnel involved in the plan’s execution. At a minimum the Contingency Plan shall be tested annually. The types of validation/testing exercises include tabletop and technical testing. Contingency Plans for all application systems must be tested at a minimum using the tabletop testing process. However, if the application system Contingency Plan is included in the technical testing of their respective support systems that technical test will satisfy the annual requirement.

Tabletop Testing

Tabletop Testing is conducted in accordance with the the CMS Risk Management Handbook, Volume 2. The primary objective of the tabletop test is to ensure designated personnel are knowledgeable and capable of performing the notification/activation requirements and procedures as outlined in the Contingency Plan, in a timely manner. The exercises include, but are not limited to:

  • Testing to validate the ability to respond to a crisis in a coordinated, timely, and effective manner, by simulating the occurrence of a specific crisis.

Technical Testing

The primary objective of the technical test is to ensure the communication processes and data storage and recovery processes can function at an alternate site to perform the functions and capabilities of the system within the designated requirements. Technical testing shall include, but is not limited to:

  • Process from backup system at the alternate site;
  • Restore system using backups; and
  • Switch compute and storage resources to alternate processing site.

1. Notification and Activation Phase

This phase addresses the initial actions taken to detect and assess damage inflicted by a disruption to C3LX. Based on the assessment of the Event, sometimes according to the C3LX Incident Response Policy, the Contingency Plan may be activated by Engineering Lead.

The notification sequence is listed below:

  • The first responder is to notify the Engineering Lead. All known information must be relayed to the Engineering Lead.
  • The Engineering Lead is to contact the Web Services Team, inform them of the event, and begin assessment procedures.
  • The Engineering Lead is to notify team members and direct them to complete the assessment procedures outlined below to determine the extent of damage and estimated recovery time. If damage assessment cannot be performed locally because of unsafe conditions, the Engineering Lead is to follow the steps below.
    • Damage Assessment Procedures:
    • The Engineering Lead is to logically assess damage, gain insight into whether the infrastructure is salvageable, and begin to formulate a plan for recovery.
    • Alternate Assessment Procedures:
    • The Engineering Lead is to follow the procedures for damage assessment with combined Dev Ops and Web Services Teams.
  • The C3LX Contingency Plan is to be activated if one or more of the following criteria are met:
    • C3LX will be unavailable for more than 48 hours.
    • Hosting facility is damaged and will be unavailable for more than 24 hours.
    • Other criteria, as appropriate and as defined by C3LX.
    • If the plan is to be activated, the Engineering Lead is to notify and inform team members of the details of the event and if relocation is required.
    • Upon notification from the Engineering Lead, group leaders and managers are to notify their respective teams. Team members are to be informed of all applicable information and prepared to respond and relocate if necessary.
    • The Engineering Lead is to notify the hosting facility partners that a contingency event has been declared and to ship the necessary materials (as determined by damage assessment) to the alternate site.
    • The Engineering Lead is to notify remaining personnel and executive leadership on the general status of the incident.
    • Notification can be message, email, or phone.

2. Recovery Phase

This section provides procedures for recovering the application at an alternate site, whereas other efforts are directed to repair damage to the original system and capabilities.

The following procedures are for recovering the C3LX's infrastructure at the alternate site. Procedures are outlined per team required. Each procedure should be executed in the sequence it is presented to maintain efficient operations.

Recovery Goal: The goal is to rebuild C3LX infrastructure to a production state.

The tasks outlines below are not sequential and some can be run in parallel.

  • Contact Partners and Customers affected - Web Services
  • Assess damage to the environment - Web Services
  • Begin replication of new environment using automated and tested scrips, currently Salt. At this point it is determined whether to recover in Rackspace, AWS, Azure, or SoftLayer. - Dev Ops
  • Test new environment using pre-written tests - Web Services
  • Test logging, security, and alerting functionality - Dev Ops
  • Assure systems are appropriately patched and up to date. - Dev Ops
  • Deploy environment to production - Web Services
  • Update DNS to new environment. - Dev Ops

3. Reconstitution Phase

This section discusses activities necessary for restoring C3LX operations at the original or new site. The goal is to restore full operations within 24 hours of a disaster or outage. When the hosted data center at the original or new site has been restored, C3LX operations at the alternate site may be transitioned back. The goal is to provide a seamless transition of operations from the alternate site to the computer center.

  1. Original or New Site Restoration
  • Begin replication of new environment using automated and tested scrips, currently Salt. - Dev Ops
  • Test new environment using pre-written tests. - Web Services
  • Test logging, security, and alerting functionality. - Dev Ops
  • Deploy environment to production - Web Services
  • Assure systems are appropriately patched and up to date. - Dev Ops
  • Update DNS to new environment. - Dev Ops
    1. Plan Deactivation

If the C3LX environment is moved back to the original site from the alternative site, all hardware used at the alternate site should be handled and disposed of according to the C3LX Media Disposal Policy.

Disposable Media Policy

C3LX recognizes that media containing ePHI may be reused when appropriate steps are taken to ensure that all stored ePHI has been effectively rendered inaccessible. Destruction/disposal of ePHI shall be carried out in accordance with federal and state law. The schedule for destruction/disposal shall be suspended for ePHI involved in any open investigation, audit, or litigation.

C3LX utilizes dedicated hardware from Subcontractors. ePHI is only stored on SSD volumes in our hosted environment. All SSD volumes utilized by C3LX is encrypted. C3LX does not use, own, or manage any mobile devices, SD cards, or tapes that have access to ePHI.

Applicable Standards from the HITRUST Common Security Framework

  • 0.9o - Management of Removable Media

Applicable Standards from the HIPAA Security Rule

  • 164.310(d)(1) - Device and Media Controls

Disposable Media Policy

  1. All removable media is restricted, audited, and is encrypted.
  2. C3LX assumes all disposable media in its Platform may contain ePHI, so it treats all disposable media with the same protections and disposal policies.
  3. All destruction/disposal of ePHI media will be done in accordance with federal and state laws and regulations and pursuant to the C3LX's written retention policy/schedule. Records that have satisfied the period of retention will be destroyed/disposed of in an appropriate manner.
  4. Records involved in any open investigation, audit or litigation should not be destroyed/disposed of. If notification is received that any of the above situations have occurred or there is the potential for such, the record retention schedule shall be suspended for these records until such time as the situation has been resolved. If the records have been requested in the course of a judicial or administrative hearing, a qualified protective order will be obtained to ensure that the records are returned to the organization or properly destroyed/disposed of by the requesting party.
  5. Before reuse of any media, for example all ePHI is rendered inaccessible, cleaned, or scrubbed. All media is formatted to restrict future access.
  6. All C3LX Subcontractors provide that, upon termination of the contract, they will return or destroy/dispose of all patient health information. In cases where the return or destruction/disposal is not feasible, the contract limits the use and disclosure of the information to the purposes that prevent its return or destruction/disposal.
  7. Any media containing ePHI is disposed using a method that ensures the ePHI could not be readily recovered or reconstructed.
  8. The methods of destruction, disposal, and reuse are reassessed periodically, based on current technology, accepted practices, and availability of timely and cost-effective destruction, disposal, and reuse technologies and services.
  9. In the case of a C3LX Customer terminating a contract with C3LX and no longer utilizing C3LX Services, the following actions will be taken depending on the C3LX Services in use. In all cases it is solely the responsibility of the C3LX Customer to maintain the safeguards required of HIPAA once the data is transmitted out of C3LX Systems.
    • In the case of a Client termination, C3LX will provide the customer with the ability to export data in commonly used format, currently CSV, for 30 days from the time of termination.
    • In the case of a User termination, C3LX will provide the customer with 30 days from the date of termination to export data.

IDS Policy

In order to preserve the integrity of data that C3LX stores, processes, or transmits for Customers, C3LX implements strong intrusion detection tools and policies to proactively track and retroactively investigate unauthorized access. C3LX currently utilizes Threatstack to track file system integrity, monitor log data, and detect rootkit access.

Applicable Standards from the HITRUST Common Security Framework

  • 09.ab - Monitoring System Use
  • 06.e - Prevention of Misuse of Information
  • 10.h - Control of Operational Software

Applicable Standards from the HIPAA Security Rule

  • 164.312(b) - Audit Controls

Intrusion Detection Policy

  • Threatstack is used to monitor and correlate log data from different systems on an ongoing basis. Reports generated by Threatstack are reviewed by the Security Officer on a monthly basis.
  • Threatstack generates alerts to analyze and investigate suspicious activity or suspected violations.
  • Threatstack monitors file system integrity and sends real time alerts when suspicious changes are made to the file system.
  • Automatic monitoring is done to identify patterns that might signify the lack of availability of certain services and systems (DOS attacks).
  • C3LX firewalls monitor all incoming traffic to detect potential denial of service attacks. Suspected attack sources are blocked automatically. Additionally, our hosting provider actively monitors its network to detect denial of services attacks.
  • All new firewall rules and configuration changes are tested before being pushed into production. All firewall and router rules are reviewed every quarter.
  • C3LX utilizes redundant firewall on network perimeters via Aptible.
  • Static IP addresses are used for C3LX servers.

Vulnerability Scanning Policy

C3LX is proactive about information security and understands that vulnerabilities need to be monitored on an ongoing basis. C3LX utilizes Threatstack to consistently scan, identify, and address vulnerabilities on our systems. We also utilize Threatstack on all systems, including logs, for file integrity checking and intrusion detection.

Applicable Standards from the HITRUST Common Security Framework

  • 10.m - Control of Technical Vulnerabilities

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(8) - Evaluation

Vulnerability Scanning Policy

  • Threatstack management is performed by the C3LX Security Officer with assistance from the Engineering Lead.
  • Threatstack is used to monitor all internal IP addresses (servers, VMs, etc) on C3LX networks.
  • Frequency of scanning is as follows:
    1. on a weekly basis;
    2. after every production deployment.
  • Reviewing Threatstack reports and findings, as well as any further investigation into discovered vulnerabilities, are the responsibility of the C3LX Security Officer.
  • In the case of new vulnerabilities, the following steps are taken:
    1. All new vulnerabilities are verified manually to assure they are repeatable. Those not found to be repeatable are manually tested after the next vulnerability scan, regardless of if the specific vulnerability is discovered again.
    2. Vulnerabilities that are repeatable manually are documented and reviewed by the Security Officer, Engineering Lead, and Privacy Officer to see if they are part of the current risk assessment performed by C3LX.
      • Those that are a part of the current risk assessment are checked for mitigations.
      • Those that are not part of the current risk assessment trigger a new risk assessment, and this process is outlined in detail in the C3LX Risk Assessment Policy.
  • All vulnerability scanning reports are retained for 6 years by C3LX.
  • Penetration testing is performed regularly as part of the C3LX vulnerability management policy.
    • External penetration testing is performed annually by a third party.
    • Internal penetration testing is bi-annually.
    • Gaps and vulnerabilities identified during penetration testing are reviewed, with plans for correction and/or mitigation, by the C3LX Security Officer.
    • Penetration tests results are retained for 6 years by C3LX.
  • This vulnerability policy is reviewed on an annual basis by the Security Officer and Privacy Officer.

Data Integrity Policy

C3LX takes data integrity very seriously. As stewards and partners of C3LX Customers, we strive to assure data is protected from unauthorized access and that it is available when needed. The following policies drive many of our procedures and technical settings in support of the C3LX mission of data protection.

Applicable Standards from the HITRUST Common Security Framework

  • 10.b - Input Data Validation

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(8) - Evaluation

Data integrity Policy

Production Systems that create, receive, store, or transmit customer data (hereafter "Production Systems") must follow the following guidelines.

Disabling non-essential services

  • All Production Systems must disable services that are not required to achieve the business purpose or function of the system.

Monitoring Log-in Attempts

  • All access to Production Systems must be logged. This is done following the C3LX Auditing Policy.

Prevention of malware on Production Systems

  • All Production Systems must have Threatstack running at set to scan system every 2 hours and at reboot to assure not malware is present. Detected malware is evaluated and removed.
  • All Production Systems are to only be used for C3LX business needs.

Patch Management

  • Patches, application, and system OS versions are kept up to date at all times. New versions are tested.
  • Administrators subscribe to mailing lists to assure up to date on current version of all C3LX managed software on Production Systems.

Intrusion Detection and Vulnerability Scanning

  • Production Systems are monitors using IDS systems. Suspicious activity is logged and alerts are generated.
  • Vulnerability scanning of Production Systems must occur on a predetermined, regular basis, no less than annually. Scans are reviewed by Security Officer, with defined steps for risk mitigation, and retained for future reference.

Production System Security

  • System, network, and server security is managed and maintained by the Engineering Lead and the Security Officer.
  • Up to date system lists and architecture diagrams are kept for all Production environments.
  • Access to Production Systems is controlled using centralized tools and two-factor authentication.

Production Data Security

  • Reduce the risk of compromise of Production Data.
  • Implement and/or review controls designed to protect Production Data from improper alteration or destruction.
  • Ensure that Confidential data is stored in a manner that supports user access logs and automated monitoring for potential security incidents.
  • Ensure C3LX customer Production Data is segmented and only accessible to customer authorized to access data.
  • All Production Data at rest is stored on encrypted volumes. Encryption at rest is ensured through the use of automated deployment scripts referenced in the C3LX Configuration Management Policy.
  • Volume encryption keys and machines that generate volume encryption keys are protected from unauthorized access. Volume encryption key material is protected with access controls such that the key material is only accessible by privileged accounts.
  • Encrypted volumes use AES encryption with a minimum of 256-bit keys, or keys and ciphers of equivalent or higher cryptographic strength.

Transmission Security

  • All data transmission is encrypted end to end. Encryption is not terminated at the network end point, and is carried through to the application.
  • Transmission encryption keys and machines that generate keys are protected from unauthorized access. Transmission encryption key material is protected with access controls such that the key material is only accessible by privileged accounts.
  • Transmission encryption keys use a minimum of 4096-bit RSA keys, or keys and ciphers of equivalent or higher cryptographic strength.
  • Transmission encryption keys are limited to use for one year and then must be regenerated.
  • In the case of C3LX provided APIs, provide mechanisms to assure person sending or receiving data is authorized to send and save data.
  • System logs of all transmissions of Production Data access. These logs must be available for audit.

Data Retention Policy

Despite not being a requirement within HIPAA, C3LX understands and appreciates the importance of health data retention. Acting as a business associate, C3LX is not directly responsible for health and medical records retention as set forth by each state. Despite this, C3LX has created and implemented the following policy to make it easier for C3LX Customers to support data retention laws.

State Medical Record Laws

Data Retention Policy

  • Current C3LX Customers have data stored by C3LX as a part of the C3LX Platform.
  • Once a Customer ceases to be a Customer, as defined below, the following steps are
    1. Customer is sent a notice via email of change of standing, and given the option to reinstate account.
    2. If no response to notice in #1 above within 7 days, or if Customer responds they do not want to reinstate account, Customer is sent directions for how to download their data from C3LX and/or to have C3LX continue to store the data at a rate of $1/month for up to 1GB. If there is more than 1GB of data, C3LX will work with Customer to determine storage costs.
    3. If Customer downloads data or does not respond to notices from C3LX within 30 days, C3LX removes data from C3LX systems and Customer is sent notice of removal of data.

Employees Policy

C3LX is committed to ensuring all workforce members actively address security and compliance in their roles at C3LX. As such, training is imperative to assuring an understanding of current best practices, the different types and sensitivities of data, and the sanctions associated with non-compliance.

Applicable Standards from the HITRUST Common Security Framework

  • 02.e - Information Security Awareness, Education, and Training
  • 06.e - Prevention of Misuse of Information Assets
  • 07.c - Acceptable Use of Assets
  • 08.j - Controls Against Malicious Code
  • 01.y - Teleworking

Applicable Standards from the HIPAA Security Rule

  • 164.308(a)(5)(i) - Security Awareness and Training

Employment Policies

  1. All new workforce members, including contractors, are given training on security policies and procedures, including operations security, within 30 days of employment.

    • Records of training are kept for all workforce members.
    • Upon completion of training, workforce members complete this form. (google form)
    • Ongoing security training is conducted monthly.
    • Current C3LX training is hosted here. source code: https://github.com/c3lx/training
  2. All workforce members are granted access to formal organizational policies, which include the sanction policy for security violations.
  3. The C3LX Employee Handbook clearly states the responsibilities and acceptable behavior regarding information system usage, including rules for email, Internet, mobile devices and social media usage.
  4. C3LX does not allow mobile devices to connect to any of its production networks.
  5. All workforce members are educated about the approved set of tools to be installed on workstations.
  6. All new workforce members are given HIPAA training within 60 days of beginning employment. Training includes HIPAA reporting requirements, including the ability to anonymously report security incidents, and the levels of compliance and obligations for C3LX and its Customers and Partners.
  7. All remote (teleworking) workforce members are trained on the risks, the controls implemented, their responsibilities, and sanctions associated with violation of policies.
  8. Employees may only use C3LX-purchased and -owned workstations for accessing production systems with access to ePHI data.
    • Any workstations used to access production systems must be configured as prescribed by the Employee Workstation Use section of the Systems Access Policy.
    • Any workstations used to access production systems must have virus protection software installed, configured, and enabled.
  9. Access to internal C3LX systems can be requested using this form. All requests for access much be granted to the C3LX Security Officer.
  10. Request for modifications of access for any C3LX employee can be made using this form.

Approved Tools Policy

C3LX utilizes a suite of approved software tools for internal use by workforce members. These software tools are either self-hosted, with security managed by C3LX, or they are hosted by a Subcontractor with appropriate business associate agreements in place to preserve data integrity. Use of other tools requires approval from C3LX leadership.

List of Approved Tools

  • Github. Github is an open source tool built on top of Git, the version control platform. Github is utilized for storage of configuration scripts and other infrastructure automation tools, as well as for source and version control of application code used by C3LX.

  • Box. Box is used for storage of files and sharing of files with Partners and Customers.

  • Microsoft Office. Microsoft Office, Outlook is used for email.

3rd Party Policy

C3LX makes every effort to assure all 3rd party organizations are compliant and do not compromise the integrity, security, and privacy of C3LX or C3LX Customer data. 3rd Parties include Customers, Partners, Subcontractors, and Contracted Developers.

Applicable Standards from the HITRUST Common Security Framework

  • 05.i - Identification of Risks Related to External Parties
  • 05.k - Addressing Security in Third Party Agreements
  • 09.e - Service Delivery
  • 09.f - Monitoring and Review of Third Party Services
  • 09.g - Managing Changes to Third Party Services
  • 10.1 - Outsourced Software Development

Applicable Standards from the HIPAA Security Rule

  • 164.314(a)(1)(i) - Business Associate Contracts or Other Arrangements

Policies to Assure 3rd Parties Support C3LX Compliance

  1. The following steps are required before 3rd parties are granted access to any C3LX systems:
    • Due diligence with the 3rd party;
    • Controls implemented to maintain compliance;
    • Written agreements, with appropriate security requirements, are executed.
  2. All connections and data in transit between the C3LX Platform and 3rd parties are encrypted end to end.
  3. Access granted to external parties is limited to the minimum necessary and granted only for the duration required.
  4. A standard business associate agreement with Clients and Partners is defined and includes the required security controls in accordance with the organization’s security policies. Additionally, responsibility is assigned in these agreements.
  5. C3LX has Service Level Agreements (SLAs) with Subcontractors with an agreed service arrangement addressing liability, service definitions, security controls, and aspects of services management.
    • C3LX utilizes monitoring tools to regularly evaluate Subcontractors against relevant SLAs.
  6. Third parties are unable to make changes to any C3LX infrastructure without explicit permission from C3LX. Additionally, no C3LX Customers or Partners have access outside of their own environment, meaning they cannot access, modify, or delete anything related to other 3rd parties.
  7. Whenever outsourced development is utilized by C3LX, all changes to production systems will be approved and implemented by C3LX workforce members only. All outsourced development requires a formal contract with C3LX.
  8. C3LX maintains and annually reviews a list all current Partners and Subcontractors.
  9. C3LX assesses security requirements and compliance considerations with all Partners and Subcontracts.
    • C3LX leverages recurring calendar invites to assure reviews of SLAs with all 3rd parties are performed annually. These are performed by the C3LX Security Officer and Privacy Officer. Google Forms are used to track such reviews.
  10. Regular review is conducted as required by SLAs to assure security and compliance. These reviews include reports, audit trails, security events, operational issues, failures and disruptions, and identified issues are investigated and resolved in a reasonable and timely manner.
  11. Any changes to Partner and Subcontractor services and systems are reviewed before implementation.
  12. For all partners, C3LX reviews activity annually to assure partners are in line with SLAs in contracts with C3LX.

Key Definitions

  • Application: An application hosted by C3LX, either maintained and created by C3LX, or maintained and created by a Customer or Partner.

  • Application Level: Controls and security associated with an Application.

  • Audit: Internal process of reviewing information system access and activity (e.g., log-ins, file accesses, and security incidents). An audit may be done as a periodic event, as a result of a patient complaint, or suspicion of employee wrongdoing.

  • Audit Controls: Technical mechanisms that track and record computer/system activities.

  • Audit Logs: Encrypted records of activity maintained by the system which provide: 1) date and time of activity; 2) origin of activity (app); 3) identification of user doing activity; and 4) data accessed as part of activity.

  • Access: Means the ability or the means necessary to read, write, modify, or communicate data/ information or otherwise use any system resource.

  • Backup: The process of making an electronic copy of data stored in a computer system. This can either be complete, meaning all data and programs, or incremental, including just the data that changed from the previous backup.

  • Backup Service: A logging service for unifying system and application logs, encrypting them, and providing a dashboard for them.

  • Breach: Means the acquisition, access, use, or disclosure of protected health information (PHI) in a manner not permitted under the Privacy Rule which compromises the security or privacy of the PHI. For purpose of this definition, “compromises the security or privacy of the PHI” means poses a significant risk of financial, reputational, or other harm to the individual. A use or disclosure of PHI that does not include the identifiers listed at §164.514(e)(2), limited data set, date of birth, and zip code does not compromise the security or privacy of the PHI. Breach excludes:

    1. Any unintentional acquisition, access or use of PHI by a workforce member or person acting under the authority of a Covered Entity (CE) or Business Associate (BA) if such acquisition, access, or use was made in good faith and within the scope of authority and does not result in further use or disclosure in a manner not permitted under the Privacy Rule.
    2. Any inadvertent disclosure by a person who is authorized to access PHI at a CE or BA to another person authorized to access PHI at the same CE or BA, or organized health care arrangement in which the CE participates, and the information received as a result of such disclosure is not further used or disclosed in a manner not permitted under the Privacy Rule.
    3. A disclosure of PHI where a CE or BA has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain such information.
  • Business Associate: A person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.

  • Covered Entity: A health plan, health care clearinghouse, or a healthcare provider who transmits any health information in electronic form.

  • De-identification: The process of removing identifiable information so that data is rendered to not be PHI.

  • Disaster Recovery: The ability to recover a system and data after being made unavailable.

  • Disaster Recovery Service: A disaster recovery service for disaster recovery in the case of system unavailability. This includes both the technical and the non-technical (process) required to effectively stand up an application after an outage.

  • Disclosure: Disclosure means the release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information.

  • Customers: Contractually bound users of C3LX Platform.

  • Electronic Protected Health Information (ePHI): Any individually identifiable health information protected by HIPAA that is transmitted by, processed in some way, or stored in electronic media.

  • Environment: The overall technical environment, including all servers, network devices, and applications.

  • Event: An event is defined as an occurrence that does not constitute a serious adverse effect on C3LX, its operations, or its Customers, though it may be less than optimal. Examples of events include, but are not limited to:

    • A hard drive malfunction that requires replacement;
    • Systems become unavailable due to power outage that is non-hostile in nature, with redundancy to assure ongoing availability of data;
    • Accidental lockout of an account due to incorrectly entering a password multiple times.
  • Hardware (or hard drive): Any computing device able to create and store ePHI.

  • Health and Human Services (HHS): The government body that maintains HIPAA.

  • Individually Identifiable Health Information: That information that is a subset of health information, including demographic information collected from an individual, and is created or received by a health care provider, health plan, employer, or health care clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and identifies the individual; or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

  • Indication: A sign that an Incident may have occurred or may be occurring at the present time. Examples of indications include:

    • The network intrusion detection sensor alerts when a known exploit occurs against an FTP server. Intrusion detection is generally reactive, looking only for footprints of known attacks. It is important to note that many IDS “hits” are also false positives and are neither an event nor an incident;
    • The antivirus software alerts when it detects that a host is infected with a worm;
    • Users complain of slow access to hosts on the Internet;
    • The system administrator sees a filename with unusual characteristics;
    • Automated alerts of activity from log monitors like Threatstack;
    • An alert from Threatstack about file system integrity issues.
  • Intrusion Detection System (IDS): A software tool use to automatically detect and notify in the event of possible unauthorized network and/or system access.

  • IDS Service: An Intrusion Detection Service for providing IDS notification to customers in the case of suspicious activity.

  • Law Enforcement Official: Any officer or employee of an agency or authority of the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, who is empowered by law to investigate or conduct an official inquiry into a potential violation of law; or prosecute or otherwise conduct a criminal, civil, or administrative proceeding arising from an alleged violation of law.

  • Logging Service: A logging service for unifying system and application logs, encrypting them, and providing a dashboard for them.

  • Messaging: API-based services to deliver and receive SMS messages.

  • Minimum Necessary Information: Protected health information that is the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. The “minimum necessary” standard applies to all protected health information in any form.

  • Off-Site: For the purpose of storage of Backup media, off-site is defined as any location separate from the building in which the backup was created. It must be physically separate from the creating site.

  • Organization: For the purposes of this policy, the term “organization” shall mean C3LX.

  • Partner: Contractual bound 3rd party vendor with integration with the C3LX Platform. May offer Add-on services.

  • Platform: The overall technical environment of C3LX.

  • Protected Health Information (PHI): Individually identifiable health information that is created by or received by the organization, including demographic information, that identifies an individual, or provides a reasonable basis to believe the information can be used to identify an individual, and relates to:

    • Past, present or future physical or mental health or condition of an individual.
    • The provision of health care to an individual.
    • The past, present, or future payment for the provision of health care to an individual.
  • Role: The category or class of person or persons doing a type of job, defined by a set of similar or identical responsibilities.

  • Sanitization: Removal or the act of overwriting data to a point of preventing the recovery of the data on the device or media that is being sanitized. Sanitization is typically done before re-issuing a device or media, donating equipment that contained sensitive information or returning leased equipment to the lending company.

  • Trigger Event: Activities that may be indicative of a security breach that require further investigation (See Appendix).

  • Restricted Area: Those areas of the building(s) where protected health information and/or sensitive organizational information is stored, utilized, or accessible at any time.

  • Role: The category or class of person or persons doing a type of job, defined by a set of similar or identical responsibilities.

  • Precursor: A sign that an Incident may occur in the future. Examples of precursors include:

    • Suspicious network and host-based IDS events/attacks;
    • Alerts as a result of detecting malicious code at the network and host levels;
    • Alerts from file integrity checking software;
    • Audit log alerts.
  • Risk: The likelihood that a threat will exploit a vulnerability, and the impact of that event on the confidentiality, availability, and integrity of ePHI, other confidential or proprietary electronic information, and other system assets.

  • Risk Management Team: Individuals who are knowledgeable about the Organization’s HIPAA Privacy, Security and HITECH policies, procedures, training program, computer system set up, and technical security controls, and who are responsible for the risk management process and procedures outlined below.

  • Risk Assessment: (Referred to as Risk Analysis in the HIPAA Security Rule); the process:

    • Identifies the risks to information system security and determines the probability of occurrence and the resulting impact for each threat/vulnerability pair identified given the security controls in place;
    • Prioritizes risks; and
    • Results in recommended possible actions/controls that could reduce or offset the determined risk.
  • Risk Management: Within this policy, it refers to two major process components: risk assessment and risk mitigation. This differs from the HIPAA Security Rule, which defines it as a risk mitigation process only. The definition used in this policy is consistent with the one used in documents published by the National Institute of Standards and Technology (NIST).

  • Risk Mitigation: Referred to as Risk Management in the HIPAA Security Rule, and is a process that prioritizes, evaluates, and implements security controls that will reduce or offset the risks determined in the risk assessment process to satisfactory levels within an organization given its mission and available resources.

  • Security Incident (or just Incident): A security incident is an occurrence that exercises a significant adverse effect on people, process, technology, or data. Security incidents include, but are not limited to:

    • A system or network breach accomplished by an internal or external entity; this breach can be inadvertent or malicious;
    • Unauthorized disclosure;
    • Unauthorized change or destruction of ePHI (i.e. delete dictation, data alterations not following C3LX’s procedures);
    • Denial of service not attributable to identifiable physical, environmental, human or technology causes;
    • Disaster or enacted threat to business continuity;
    • Information Security Incident: A violation or imminent threat of violation of information security policies, acceptable use policies, or standard security practices. Examples of information security incidents may include, but are not limited to, the following:
    • Denial of Service: An attack that prevents or impairs the authorized use of networks, systems, or applications by exhausting resources;
    • Malicious Code: A virus, worm, Trojan horse, or other code-based malicious entity that infects a host;
    • Unauthorized Access/System Hijacking: A person gains logical or physical access without permission to a network, system, application, data, or other resource. Hijacking occurs when an attacker takes control of network devices or workstations;
    • Inappropriate Usage: A person violates acceptable computing use policies;
    • Other examples of observable information security incidents may include, but are not limited to:
      • Use of another person’s individual password and/or account to login to a system;
      • Failure to protect passwords and/or access codes (e.g., posting passwords on equipment);
      • Installation of unauthorized software;
      • Terminated workforce member accessing applications, systems, or network.
  • Threat: The potential for a particular threat-source to successfully exercise a particular vulnerability. Threats are commonly categorized as:

    • Environmental – external fires, HVAC failure/temperature inadequacy, water pipe burst, power failure/fluctuation, etc.
    • Human – hackers, data entry, workforce/ex-workforce members, impersonation, insertion of malicious code, theft, viruses, SPAM, vandalism, etc.
    • Natural – fires, floods, electrical storms, tornados, etc.
    • Technological – server failure, software failure, ancillary equipment failure, etc. and environmental threats, such as power outages, hazardous material spills.
    • Other – explosions, medical emergencies, misuse or resources, etc.
  • Threat Source: Any circumstance or event with the potential to cause harm (intentional or unintentional) to an IT system. Common threat sources can be natural, human or environmental which can impact the organization’s ability to protect ePHI.

  • Threat Action: The method by which an attack might be carried out (e.g., hacking, system intrusion, etc.).

  • Unrestricted Area: Those areas of the building(s) where protected health information and/or sensitive organizational information is not stored or is not utilized or is not accessible there on a regular basis.

  • Unsecured Protected Health Information: Protected health information (PHI) that is not rendered unusable, unreadable, or indecipherable to unauthorized individuals through the use of technology or methodology specified by the Secretary in the guidance issued under section 13402(h)(2) of Pub. L.111-5 on the HHS website.

    1. Electronic PHI has been encrypted as specified in the HIPAA Security rule by the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without the use of a confidential process or key and such confidential process or key that might enable decryption has not been breached. To avoid a breach of the confidential process or key, these decryption tools should be stored on a device or at a location separate from the data they are used to encrypt or decrypt. The following encryption processes meet this standard.
    2. Valid encryption processes for data at rest (i.e. data that resides in databases, file systems and other structured storage systems) are consistent with NIST Special Publication 800-111, Guide to Storage Encryption Technologies for End User Devices.
    3. Valid encryption processes for data in motion (i.e. data that is moving through a network, including wireless transmission) are those that comply, as appropriate, with NIST Special Publications 800-52, Guidelines for the Selection and Use of Transport Layer Security (TLS) Implementations; 800-77, Guide to IPSec VPNs; or 800-113, Guide to SSL VPNs, and may include others which are Federal Information Processing Standards FIPS 140-2 validated.
    4. The media on which the PHI is stored or recorded has been destroyed in the following ways:
    5. Paper, film, or other hard copy media have been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed. Redaction is specifically excluded as a means of data destruction.
    6. Electronic media have been cleared, purged, or destroyed consistent with NIST Special Publications 800-88, Guidelines for Media Sanitization, such that the PHI cannot be retrieved.
  • Vendors: Persons from other organizations marketing or selling products or services, or providing services to C3LX.

  • Vulnerability: A weakness or flaw in an information system that can be accidentally triggered or intentionally exploited by a threat and lead to a compromise in the integrity of that system, i.e., resulting in a security breach or violation of policy.

  • Workstation: An electronic computing device, such as a laptop or desktop computer, or any other device that performs similar functions, used to create, receive, maintain, or transmit ePHI. Workstation devices may include, but are not limited to: laptop or desktop computers, personal digital assistants (PDAs), tablet PCs, and other handheld devices. For the purposes of this policy, “workstation” also includes the combination of hardware, operating system, application software, and network connection.

  • Workforce: Means employees, volunteers, trainees, 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

HIPAA Mappings to C3LX Controls

Below is a list of HIPAA Safeguards and Requirements and the C3LX controls in place to meet those.

Administrative Controls HIPAA Rule C3LX Control
Security Management Process - 164.308(a)(1)(i) Risk Management Policy
Assigned Security Responsibility - 164.308(a)(2) Roles Policy
Workforce Security - 164.308(a)(3)(i) Employee Policies
Information Access Management - 164.308(a)(4)(i) System Access Policy
Security Awareness and Training - 164.308(a)(5)(i) Employee Policy
Security Incident Procedures - 164.308(a)(6)(i) IDS Policy
Contingency Plan - 164.308(a)(7)(i) Disaster Recovery Policy
Evaluation - 164.308(a)(8) Auditing Policy
Physical Safeguards HIPAA Rule C3LX Control
Facility Access Controls - 164.310(a)(1) Facility and Disaster Recovery Policies
Workstation Use - 164.310(b) System Access, Approved Tools, and Employee Policies
Workstation Security - 164.310('c') System Access, Approved Tools, and Employee Policies
Device and Media Controls - 164.310(d)(1) Disposable Media and Data Management Policies
Technical Safeguards HIPAA Rule C3LX Control
Access Control - 164.312(a)(1) System Access Policy
Audit Controls - 164.312(b) Auditing Policy
Integrity - 164.312('c')(1) System Access, Auditing, and IDS Policies
Person or Entity Authentication - 164.312(d) System Access Policy
Transmission Security - 164.312(e)(1) System Access and Data Management Policy
Organizational Requirements HIPAA Rule C3LX Control
Business Associate Contracts or Other Arrangements - 164.314(a)(1)(i) Business Associate Agreements and 3rd Parties Policies
Policies and Procedures and Documentation Requirements HIPAA Rule C3LX Control
Policies and Procedures - 164.316(a) Policy Management Policy
Documentation - 164.316(b)(1)(i) Policy Management Policy
HITECH Act - Security Provisions HIPAA Rule C3LX Control
Notification in the Case of Breach - 13402(a) and (b) Breach Policy
Timelines of Notification - 13402(d)(1) Breach Policy
Content of Notification - 13402(f)(1) Breach Policy