Information security management system

Effortless Admin's security policies and procedures

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11​ Breach Policy

To provide guidance for breach notification when impressive or unauthorized access, acquisition, use and/or disclosure of the ePHI occurs. In the case of a breach, EA shall notify all affected Customers. It is the responsibility of the Customers to notify affected individuals.

​11.1​ EA 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 EA (includes breaches by the organization’s Customers, Partners, or subcontractors). EA 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. EA shall also begin the process of determining what external notifications are required or should be made (e.g., media outlets, law enforcement officials, etc.)
  2. Breach Investigation: The EA 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., 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.
  3. Risk Assessment: For an acquisition, access, use or disclosure of ePHI to constitute a breach, it must constitute a violation of the PIPEDA regulations. 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, EA, 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 EA Customers no later than 4 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 time 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, 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 EA 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: EA Customers will be notified via email 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, EA 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, 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: EA 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: EA 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: EA 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 as a condition of the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits.

​11.2​ EA Platform Customer Responsibilities

  1. The EA Customer that accesses, maintains, retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses unsecured ePHI shall, without unreasonable delay and in no case later than 60 calendar days after discovery of a breach, notify EA of such breach. The Customer shall provide EA with the following information:
    • 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 Insurance 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.
  2. Notice to Media: EA Customers are responsible for providing notice to prominent media outlets at the Customer’s discretion.

​11.3​ Sample Letter to Customers in Case of Breach

[Date]

[Name] [Name of Customer] [Address 1] [Address 2] [City, Province, Postal Code]

Dear [Name of Customer]:

I am writing to you from Effortless Admin Inc., with important information about a recent security 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:

Other Optional Considerations:

We will assist you in remedying the situation.

Sincerely,

David Ross
President - Effortless Admin Inc.
dross@effortlessadmin.com
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