Information security management system

Effortless Admin's security policies and procedures


​6​ System Access Policy

Access to EA systems and applications is limited for all users, including but not limited to workforce members, volunteers, 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 PIPEDA regulations including the following.

​6.1​ Access Establishment and Modification

  1. Requests for access to the EA Platform systems and applications is made formally using the following process:
    1. The EA workforce member, or their manager, initiates the access request by creating an Issue in the Asana Compliance Review Activity (CRA) Project.
      • User identities must be verified prior to granting access to new accounts.
      • Identity verification must be done in person where possible; for remote employees, identities may be verified over the phone.
      • For new accounts, the method used to verify the user’s identity must be recorded on the Issue.
    2. The Security Officer will grant access to systems as dictated by the employee’s job title. If additional access is required outside of the minimum necessary to perform job functions, the requester must include a description of why the additional access is required as part of the access request.
    3. Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
    4. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required. The Security Officer then grants requested access.
      • New accounts will be created with a temporary secure password that meets all requirements from Section 6.11, which must be changed on the initial login.
      • All password exchanges must occur over an authenticated channel.
      • For production systems, access grants are accomplished by adding the appropriate user account to the corresponding LDAP group.
      • For non-production systems, access grants are accomplished by leveraging the access control mechanisms built into those systems. Account management for non-production systems may be delegated to an EA employee at the discretion of the Security Officer.
    5. Access is not granted until receipt, review, and approval by the EA Security Officer;
    6. The request for access is retained for future reference.
  2. All access to EA systems and services are reviewed and updated on a bi-annual basis to ensure proper authorizations are in place commensurate with job functions. The process for conducting reviews is outlined below:
    1. The Security Officer initiates the review of user access by creating an Issue in the Asana Compliance Review Activity (CRA) Project.
    2. The Security Officer, or a Privacy Officer, is assigned to review levels of access for each EA workforce member.
    3. If user access is found during review that is not in line with the least privilege principle, the process below is used to modify user access and notify the user of access changes. Once those steps are completed, the Issue is then reviewed again.
    4. Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
    5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
    6. Review of user access is monitored on a bi-annual basis using Asana reporting to assess compliance with above policy.
  3. Any EA workforce member can request change of access using the process outlined in Section 6.1.
  4. Access to production systems is controlled using centralized user management and authentication.
  5. Temporary accounts are not used unless absolutely necessary for business purposes.
    1. Accounts are reviewed every 90 days to ensure temporary accounts are not left unnecessarily.
    2. Accounts that are inactive for over 90 days are removed or automatically expired.
  6. In the case of non-personal information, such as generic educational content, identification and authentication may not be required. This is the responsibility of EA Customers to define, and not EA.
  7. Privileged users must first access systems using standard, unique user accounts before switching to privileged users and performing privileged tasks.
    1. For production systems, this is enforced by creating non-privileged user accounts that must invoke sudo or User Account Control (UAC) to perform privileged tasks.
    2. Rights for privileged accounts are granted by the Security Officer using the process outlined in Section 6.1.
  8. 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.
  9. Generic accounts are not allowed on EA systems.
  10. Access is granted through encrypted, VPN tunnels that utilize two-factor authentication.
    1. Two-factor authentication is accomplished using a Time-based One-Time Password (TOTP) as the second factor.
    2. VPN connections use 256-bit AES 256 encryption, or equivalent.
    3. VPN sessions are automatically disconnected after 30 minutes of inactivity.
  11. 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.
  12. Direct system to system, system to application, and application to application authentication and authorization are limited and controlled to restrict access.

​6.2​ Workforce Clearance

  1. 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.
  2. All access requests are treated on a “least-access” principle.
  3. EA maintains a minimum necessary approach to access to Customer data. As such, EA, including all workforce members, does not readily have access to any ePHI.

​6.3​ Access Authorization

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

​6.4​ Person or Entity Authentication

  1. Each workforce member has and uses a unique user ID and password that identifies him/her as the user of the information system.
  2. Each Customer and Partner has and uses a unique user ID and password that identifies him/her as the user of the information system.
  3. All Customer support desk interactions must be verified before EA support personnel will satisfy any request having information security implications.
    • EA’s current support desk software, Asana, requires users to authenticate before submitting support tickets.
    • Support issues submitted by email, phone, or chat must be verified by EA personnel.

​6.5​ Unique User Identification

  1. Access to the EA Platform systems and applications is controlled by requiring unique User Login IDs and passwords for each individual user and developer.
  2. Passwords requirements mandate strong password controls (see below).
  3. Passwords are not displayed at any time and are not transmitted or stored in plain text.
  4. Default accounts on all production systems, including root, are disabled.
  5. Shared accounts are not allowed within EA systems or networks.
  6. Automated log-on configurations that store user passwords or bypass password entry are not permitted for use with EA workstations or production systems.

​6.6​ Automatic Logoff

  1. 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).
  2. Information systems automatically log users off the systems after 15 minutes of inactivity.
  3. The Security Officer pre-approves exceptions to automatic log off requirements.

​6.7​ Employee Workstation Use

All workstations at EA are company owned.

  1. Workstations may not be used to engage in any activity that is illegal or is in violation of organization’s policies.
  2. Access may not be used for transmitting, retrieving, or storage of any communications of a discriminatory or harassing nature or materials that are obscene or “X-rated”. Harassment of any kind is prohibited. No messages with derogatory or inflammatory remarks about an individual’s race, age, disability, religion, national origin, physical attributes, sexual preference, or health condition shall be transmitted or maintained. No abusive, hostile, profane, or offensive language is to be transmitted through organization’s system.
  3. 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.
  4. Solicitation of non-company business, or any use of organization’s information systems/applications for personal gain is prohibited.
  5. Transmitted messages may not contain material that criticizes the organization, its providers, its employees, or others.
  6. Users may not misrepresent, obscure, suppress, or replace another user’s identity in transmitted or stored messages.
  7. Workstation hard drives will be encrypted.
  8. All workstations have firewalls enabled to prevent unauthorized access unless explicitly granted.
  9. All workstations are to have the following messages added to the lock screen and login screen:

    This computer is owned by Effortless Admin Inc. By logging in, unlocking, and/or using this computer you acknowledge you have seen and will adhere to Effortless Admin’s policies and procedures. Please contact us if you have problems with this -

​6.8​ Wireless Access Use

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

​6.9​ Employee Termination Procedures

  1. 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”.
  2. The Human Resources Department, users, and supervisors are required to notify the Security Officer 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).
  3. The Security Officer will terminate user’s’ access rights immediately upon notification, and will coordinate with the appropriate EA employees to terminate access to any non-production systems managed by those employees.
  4. 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.

​6.10​ Paper Records

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

6.11​ Password Management

  1. User IDs and passwords are used to control access to EA systems and may not be disclosed to anyone for any reason.
  2. Users may not allow anyone, for any reason, to have access to any information system using another user’s unique user ID and password.
  3. On all production systems and applications in the EA environment, password configurations are set to require:
    • a minimum length of 8 characters;
    • a mix of upper case characters, lower case characters, and numbers or special characters; or a sentence style passphrase consisting of at least four randomly selected words;
    • a 90-day password expiration, or 60-day password expiration for administrative accounts;
    • prevention of password reuse using a history of the last 6 passwords;
    • where supported, modifying at least 4 characters when changing passwords;
    • account lockout after 5 invalid attempts.
  4. All system and application passwords must be stored and transmitted securely.
    • Where possible, passwords should be stored in a hashed format using a salted cryptographic hash function (SHA-256 or equivalent or better).
    • Passwords that must be stored in non-hashed format must be encrypted at rest pursuant to the requirements in Section 16.7.
    • Transmitted passwords must be encrypted in flight pursuant to the requirements in Section 16.8.
  5. Each information system automatically requires users to change passwords at a predetermined interval as determined by the organization, based on the criticality and sensitivity of the ePHI contained within the network, system, application, and/or database.
  6. Passwords are inactivated immediately upon an employee’s termination (refer to Section 6.9).
  7. All default system, application, and Partner passwords are changed before deployment to production.
  8. Upon initial login, users must change any passwords that were automatically generated for them.
  9. Password change methods must use a confirmation method to correct for user input errors.
  10. All passwords used in configuration scripts are secured and encrypted.
  11. If a user believes their user ID has been compromised, they are required to immediately report the incident to the Security Office.
  12. In cases where a user has forgotten their password to the internal EA network, the following procedure is used to reset the password.
    • The user submits a password reset request to The request should include the system to which the user has lost access and needs the password reset.
    • An administrator with password reset privileges is notified and connects directly with the user requesting the password reset.
    • The administrator verifies the identity of the user either in-person or through a separate communication channel such as phone or Slack.
    • Once verified, the administrator resets the password.

The Password Reset email inbox is used to track and store password reset requests. The Security Officer is the owner of this group and modifies membership as needed.

​6.12​ Access to ePHI

  1. Employees may not download ePHI to any workstations used to connect to production systems.
  2. Disallowing transfer of ePHI to workstations is enforced through technical measures.
    • All production access to systems is performed through a bastion/jump host accessed through a VPN. Direct access to production systems is disallowed by EA’s VPN configuration.
    • On production Linux bastions, all file transfer services are disabled including file-transfer functionality of SSH services (SCP/SFTP).
    • On production Windows bastions, local drive mappings are disabled by Group Policy settings.
    • Configuration settings for enforcing these technical controls are managed by EA’s configuration management tooling, Chef/Salt.
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