Information systems management system

Effortless Admin's security policies and procedures

1. Introduction

Effortless Admin (“EA”) is an administrator of employee benefit plans for Canadian employers of all sizes. EA focuses on pairing powerful software with great people to eliminate administration headaches and give their clients a competitive advantage. They also empower Canadian insurance brokers with a suite of state-of-the-art consulting tools that gives their broker partners the control and insight they need to effectively keep their fingers on the pulse of a plan’s performance.

For more information about EA and their value proposition, please visit www.effortlessadmin.com

EA 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 Customers. As providers of compliant, hosted infrastructure used by employers and Third Party Administrators (TPAs), EA strives to maintain compliance, proactively address information security, mitigate risk for its Customers, and ensure known breaches are completely and effectively communicated in a timely manner. The following addresses core policies used by EA to maintain compliance and assure the proper protections of infrastructure used to store, process, and transmit ePHI for EA Customers.

1.1 Software as a Service (SaaS)

SaaS Customers utilize hosted software and infrastructure from EA to run their TPA business. These customers are deployed into compliant containers run on systems secured and managed by EA. EA does not have insight or access into application level data of SaaS Customers and, as such, does not have the ability to secure or manage risk associated with application level vulnerabilities and security weaknesses. EA makes every effort to reduce the risk of unauthorized disclosure, access, and/or breach of SaaS Customer data through network (firewalls, dedicated IP spaces, etc) and server settings (encryption at rest and in transit, OSSEC throughout the Platform, etc).

1.2 Compliance

EA signs agreements with its Customers. These agreements outline EA obligations and Customer 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 PIPEDA as well as future compliance frameworks, EA manages various aspects of compliance for Customers. The aspects of compliance that EA manages for Customers are inherited by Customers, and EA assumes the risk associated with those aspects of compliance. In doing so, EA helps Customers achieve and maintain compliance, as well as mitigates Customer’s risk.

1.3 EA Organizational Concepts

The physical infrastructure environment is hosted at Peer1. The network components and supporting network infrastructure are contained within the Peer1 infrastructures and managed by Peer1. EA does not have physical access into the network components. The EA environment consists of firewalls, web servers and Microsoft SQL database servers.

Within the EA Platform on Peer1, all data transmission is encrypted and all hard drives are encrypted so data at rest is also encrypted; this applies to all servers, databases, APIs, log servers, etc. EA assumes all data may contain ePHI, even though our Risk Assessment does not indicate this is the case, and provides appropriate protections based on that assumption.

In the case of SaaS Customers, it is the responsibility of the Customer to restrict, secure, and assure the privacy of all ePHI data at the Application Level, as this is not under the control or purview of EA.

EA has implemented strict logical access controls so that only authorized personnel are given access to the internal management servers. The environment is configured so that data is transmitted from the load balancers to the application servers over a TLS encrypted session.

The web servers are externally facing and accessible via the Internet on predefined ports. The database servers, where the ePHI resides, are located on an internal network and can only be accessed through a VPN connection. Access to the internal database is restricted to a limited number of personnel and strictly controlled to only those personnel with a business-justified reason.

All Platform features and operating systems are tested end-to-end for usability, security, and impact prior to deployment to production.

1.4 Requesting Audit and Compliance Reports

EA, at its sole discretion, shares audit reports with customers on a case by case basis. All audit reports are shared under explicit NDA in EA format between EA and party to receive materials. Audit reports can be requested by EA workforce members for Customers or directly by EA Customers.

The following process is used to request audit reports:

Email is sent to compliance_reports@effortlessadmin.com. In the email, please specify the type of report being requested and any required timelines for the report.
EA staff will log an Issue with the details of the request into the EA Compliance Review Activities Project on Asana. Asana is used to track requests status and outcomes.
EA will confirm if a current NDA is in place with the party requesting the audit report. If there is no NDA in place, EA will send one for execution.
Once it has been confirmed that an NDA is executed, EA staff will move the Asana Issue to “Under Review”.
The EA Security Officer or Privacy Officer must Approve or Reject the Issue. If the Issue is rejected, EA will notify the requesting party that we cannot share the requested report.
If the Issue has been Approved, EA will send the customer the requested audit report and complete the Asana Issue for the request.

1.5 Version Control

Refer to the GitHub repository (https://github.com/EffortlessDev/policies) for the full version history of these policies.

2 Policy Management Policy

EA 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 ensuring all EA workforce members, 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.

2.1 Maintenance of Policies

All policies are stored and up to date to maintain EA compliance with PIPEDA, and other relevant standards. Updates and version control are done similar to source code control.
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.
EA employees may request changes to policies using the following process:
1. The EA employee initiates a policy change request by creating an Issue in the Asana Compliance Review Activity (CRA) project. The change request may optionally include a GitHub pull request from a separate branch or repository containing the desired changes.
2. The Security Officer or the Privacy Officer is assigned to review the policy change 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.
5. If the policy change requires technical modifications to production systems, those changes are carried out by authorized personnel using EA’s change management process.
All policies are made accessible to all EA workforce members. The current master policies are published at https://effortlessdev.github.io/policies/.
1. Changes are automatically communicated to all EA team members through integrations between GitHub and Slack that log all GitHub policy channels to a dedicated EA Slack Channel.
2. The Security Officer also communicates policy changes to all employees via email. These emails include a high-level description of the policy change using terminology appropriate for the target audience.
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 EA policies is done via GitHub.
2. Backup storage of all policies is done with Google Drive.
The policies and information security policies are reviewed and audited annually, or after significant changes occur to EA’s organizational environment. Issues that come up as part of this process are reviewed by EA management to assure all risks and potential gaps are mitigated and/or fully addressed. The process for reviewing policies is outlined below:
1. The Security Officer initiates the policy review by creating an Issue in the Asana Compliance Review Activity (CRA) project.
2. The Security Officer or the Privacy Officer is assigned to review the current EA policies (https://effortlessdev.github.io/policies/).
3. If changes are made, the above process is used. All changes are documented in the Issue.
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.
Policy review is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.

3 Risk Management Policy

This policy establishes the scope, objectives, and procedures of EA’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.

3.1 Risk Management Policies

It is the policy of EA 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 EA’s information security program.
Risk analysis and risk management are recognized as important components of EA’s corporate compliance program and information security program.
1. Risk assessments are done throughout product life cycles:
2. Before the integration of new system technologies and before changes are made to EA physical safeguards; and
  1. 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 EA Platform.
3. While making changes to EA physical equipment and facilities that introduce new, untested configurations.
4. EA 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.
EA 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 EA 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.
Any risk remaining (residual) after other risk controls have been applied, requires sign off by the senior management and EA’s Security Officer.
All EA 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 EA Roles Policy.
The implementation, execution, and maintenance of the information security risk analysis and risk management process is the responsibility of EA’s Security Officer (or other designated employee), and the identified Risk Management Team.
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.
The details of the Risk Management Process, including risk assessment, discovery, and mitigation, are outlined in detail below. The process is tracked, measured, and monitored using the following procedures:
1. The Security Officer or the Privacy Officer initiates the Risk Management Procedures by creating an Issue in the Asana Compliance Review Activity (CRA) Project.
2. The Security Officer or the Privacy Officer is assigned to carry out the Risk Management Procedures.
3. All findings are documented in approved spreadsheet that is linked to the Issue.
4. Once the Risk Management Procedures are complete, along with corresponding documentation, 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.
The Risk Management Procedure is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.

3.2 Risk Management Procedures

3.2.1 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 EA Platform boundaries are identified.
- Output - Characterization of the EA 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 EA 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).
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 EA’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).
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).
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 controls 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.

3.2.2 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 EA 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, EA’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 individual’s 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 EA 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

3.2.3 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 EA’s information security program:

Scheduled Basis - an overall risk assessment of EA’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 information system 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, threats, legal liabilities, or other significant factors that affect EA’s Platform.

3.3 Process Documentation

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

4 Roles Policy

EA has a Security Officer and Privacy Officer appointed to assist in maintaining and enforcing safeguards towards compliance. The responsibilities associated with these roles are outlined below.

4.1 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.

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.
Assists in the administration and oversight of agreements.
Manages relationships with customers and partners as those relationships affect security and compliance of ePHI.
Assists Security Officer as needed.

The current EA Privacy Officer is Michael Ross (privacy_officer@effortlessadmin.com).

4.1.1 Workforce Training Responsibilities

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 EA.
The Privacy Officer or designee maintains documentation of the training session materials and attendees for a minimum of six years.
The training session focuses on, but is not limited to, the following subjects defined in EA’s security policies and procedures:
1. PIPEDA Privacy, Security, and Breach notification rules;
2. Risk Management procedures and documentation;
3. Auditing. EA may monitor access and activities of all users;
4. Workstations may only be used to perform assigned job responsibilities;
5. Users may not download software onto EA’s workstations and/or systems without prior approval from the Security Officer;
6. Users are required to report malicious software to the Security Officer immediately;
7. Users are required to report unauthorized attempts, uses of, and theft of EA’s systems and/or workstations;
8. Users are required to report unauthorized access to facilities
9. 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);
10. Users may not alter ePHI maintained in a database, unless authorized to do so by an EA Customer;
11. Users are required to understand their role in EA’s contingency plan;
12. Users may not share their usernames or passwords with anyone;
13. Requirements for users to create and change passwords;
14. Users must set all applications that contain or transmit ePHI to automatically log off after 15 minutes of inactivity;
15. Supervisors are required to report terminations of workforce members and other outside users;
16. Supervisors are required to report a change in a user’s title, role, department, and/or location;
17. Procedures to backup ePHI;
18. Procedures to move and record movement of hardware and electronic media containing ePHI;
19. Procedures to dispose of discs, CDs, hard drives, and other media containing ePHI;
20. Procedures to re-use electronic media containing ePHI;
21. SSH key and sensitive document encryption procedures;
22. Restrictions, protection of, and policies relating to the usage of external storage devices, such as USB keys or external hard disks;
23. Restrictions, protection of, and policies relating to portable company equipment such as laptops and cell phones.

4.2 Security Officer

The Security Officer is responsible for facilitating the training and supervision of all workforce members, investigation and sanctioning of any workforce member that is in violation of EA security policies and non-compliance with the security regulations, and writing, implementing, and maintaining all policies, procedures, and documentation related to efforts toward security and compliance.

The current EA Security Officer is David Reid (security_officer@effortlessadmin.com).

4.2.1 Organizational Responsibilities

The Security Officer, in collaboration with the Privacy Officer, is responsible for facilitating the development, testing, implementation, training, and oversight of all activities pertaining to EA’s efforts to be compliant with the PIPEDA regulations and any other security and compliance frameworks. The intent of the Security Officer Responsibilities is to maintain the confidentiality, integrity, and availability of ePHI. The Security Officer is appointed by and reports to the Board of Directors and the CEO.

These organizational responsibilities include, but are not limited to the following:

Oversees and enforces all activities necessary to maintain compliance and verifies the activities are in alignment with the requirements.
Helps to establish and maintain written policies and procedures to comply with the Security rule and maintains them for six years from the date of creation or date it was last in effect, whichever is later.
Reviews and updates policies and procedures as necessary and appropriate to maintain compliance and maintains changes made for six years from the date of creation or date it was last in effect, whichever is later.
Facilitates audits to validate compliance efforts throughout the organization.
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.
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.
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 EA infrastructure.
Develops and provides periodic security updates and reminder communications for all workforce members.
Implements procedures for the authorization and/or supervision of workforce members who work with ePHI or in locations where it may be accessed.
Maintains a program promoting workforce members to report non-compliance with policies and procedures.
- Promptly, properly, and consistently investigates and addresses reported violations and takes steps to prevent recurrence.
- Applies consistent and appropriate sanctions against workforce members who fail to comply with the security policies and procedures of EA.
- Mitigates, to the extent practicable, any harmful effect known to EA of a use or disclosure of ePHI in violation of EA’s policies and procedures, even if effect is the result of actions of EA customers, and/or partners.
Reports security efforts and incidents to administration immediately upon discovery. Responsibilities in the case of a known ePHI breach are documented in Section 11.
The Security Officer facilitates the communication of security updates and reminders to all workforce members to which it pertains. Examples of security updates and reminders include, but are not limited to:
- Latest malicious software or virus alerts;
- EA’s requirement to report unauthorized attempts to access ePHI;
- Changes in creating or changing passwords;
- Additional security-focused training is provided to all workforce members by the Security Officer. This training includes, but is not limited to:
  - Data backup plans;
  - System auditing procedures;
  - Redundancy procedures;
  - Contingency plans;
  - Virus protection;
  - Patch management;
  - Media Disposal and/or Re-use;
  - Documentation requirements.
The Security Officer works with the CTO to ensure that any security objectives have appropriate consideration during the budgeting process.
- In general, security and compliance are core to EA’s technology and service offerings; in most cases this means security-related objectives cannot be split out to separate budget line items.
- For cases that can be split out into discrete items, such as licenses for commercial tooling, the Security Officer follows EA’s standard corporate budgeting process.
  - At the beginning of every fiscal year, the CTO contacts the Security Officer to plan for the upcoming year’s expenses.
  - The Security Officer works with the CTO to forecast spending needs based on the previous year’s level, along with changes for the upcoming year such as additional staff hires.
  - During the year, if an unforeseen security-related expense arises that was not in the budget forecast, the Security Officer works with the CTO to reallocate any resources as necessary to cover this expense.

4.2.2 Supervision of Workforce Responsibilities

Although the Security Officer is responsible for implementing and overseeing all activities related to maintaining compliance, it is the responsibility of all workforce members (i.e. team leaders, supervisors, managers, directors, co-workers, etc.) to supervise all workforce members and any other user of EA’s systems, applications, servers, workstations, etc. that contain ePHI.

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

4.2.3 Sanctions of Workforce Responsibilities

All workforce members report non-compliance of EA’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.

The Security Officer promptly facilitates a thorough investigation of all reported violations of EA’s security policies and procedures. The Security Officer may request the assistance from others.
- Complete an audit trail/log to identify and verify the violation and sequence of events.
- Interview any individual that may be aware of or involved in the incident.
- All individuals are required to cooperate with the investigation process and provide factual information to those conducting the investigation.
- Provide individuals suspected of non-compliance of the Security rule and/or EA’s policies and procedures the opportunity to explain their actions.
- The investigator thoroughly documents the investigation as the investigation occurs. This documentation must include a list of all employees involved in the violation.
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, 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 provincial laws and regulations.
- A violation resulting in a breach of confidentiality (i.e. release of PHI to an unauthorized individual), change of the integrity of any ePHI, or inability to access any ePHI by other users, requires immediate disciplinary action and may require immediate termination of the workforce member from EA.
The Security Officer facilitates taking appropriate steps to prevent recurrence of the violation (when possible and feasible).
In the case of an insider threat, the Security Officer and Privacy Officer are to set up a team to investigate and mitigate the risk of insider malicious activity. EA workforce members are encouraged to come forward with information about insider threats, and can do so anonymously.
The Security Officer maintains all documentation of the investigation, sanctions provided, and actions taken to prevent recurrence for a minimum of six years after the conclusion of the investigation.

5 Data Management Policy

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

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

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

5.1 Backup Policy and Procedures

Perform daily snapshot backups of all systems that process, store, or transmit ePHI for EA Customers, including SaaS Customers.
EA Ops Team, lead by the CTO, is designated to be in charge of backups.
Dev Ops Team members are trained and assigned to complete backups and manage the backup media.
Document backups
- Name of the system
- Date & time of backup
- Where backup stored (or to whom it was provided)
Securely encrypt stored backups in a manner that protects them from loss or environmental damage.
Test backups and document that files have been completely and accurately restored from the backup media.
Any user access to a backup will be logged for security auditing purposes.

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

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.
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.
Any EA workforce member can request change of access using the process outlined in Section 6.1.
Access to production systems is controlled using centralized user management and authentication.
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.
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.
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.
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 EA systems.
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.
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.

6.2 Workforce Clearance

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.
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

Role based access categories for each EA system and application are pre-approved by the Security Officer or CTO.
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

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.
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

Access to the EA Platform systems and applications is controlled by requiring unique User Login IDs 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 EA systems or networks.
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

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 15 minutes of inactivity.
The Security Officer pre-approves exceptions to automatic log off requirements.

6.7 Employee Workstation Use

All workstations at EA are company owned.

Workstations may not be used to engage in any activity that is illegal or is in violation of organization’s policies.
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.
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.
Transmitted messages may not contain material that criticizes the organization, its providers, its employees, or others.
Users may not misrepresent, obscure, suppress, or replace another user’s identity in transmitted or stored messages.
Workstation hard drives will be encrypted.
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 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 - privacy@effortlessadmin.com.

6.8 Wireless Access Use

EA production systems are not accessible directly over wireless channels.
Wireless access is disabled on all production systems.
When accessing 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 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

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 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).
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.
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

User IDs and passwords are used to control access to EA 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 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.
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.
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.
Passwords are inactivated immediately upon an employee’s termination (refer to Section 6.9).
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.
Password change methods must use a confirmation method to correct for user input errors.
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.
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 security_officer@effortlessadmin.com. 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

Employees may not download ePHI to any workstations used to connect to production systems.
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.

7 Auditing Policy

EA shall audit access and activity of electronic protected health information (ePHI) applications and systems. EA 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 EA to safeguard the confidentiality, integrity, and availability of applications, systems, and networks. To ensure that appropriate safeguards are in place and effective, EA 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.

7.1 Auditing Policies

Responsibility for auditing information system access and activity is assigned to EA’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 EA are monitored. Access is limited to certain services, ports, and destinations. Exceptions to these rules, if created, are reviewed on an annual basis.
EA’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. EA utilizes file system monitoring from OSSEC to assure the integrity of file system data.
- Network: Network level audit trails generally monitor information on what is operating, penetrations, and vulnerabilities.
EA 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 EA.
EA utilizes OSSEC to scan all systems for malicious and unauthorized software every 2 hours and at reboot of systems.
EA leverages process monitoring tools throughout its environment.
EA uses OSSEC to monitor the integrity of log files by utilizing OSSEC System Integrity Checking capabilities.
EA 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 EA Platform or may be specific to a Customer, partner, platform feature or application (See Listing of Potential Trigger Events below).
In addition to trigger events, EA utilizes OSSEC log correlation functionality to proactively identify and enable alerts based on log data.
Logs are reviewed weekly by the Security Officer.
EA’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.
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 EA 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.
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.
Software patches and updates will be applied to all systems in a timely manner.

7.2 Audit Requests

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, Partner or application user.
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 EA’s Privacy or Security Officer.
A request for an audit must be approved by EA’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 EA’s Security Officer to determine appropriate sanction/corrective disciplinary action.
- Only de-identified information shall be shared with Customer or Partner regarding the results of the investigative audit process. This information will be communicated to the appropriate personnel by EA’s Privacy Officer or designee. Prior to communicating with customers and partners regarding an audit, it is recommended that EA consider seeking risk management and/or legal counsel.

7.3 Review and Reporting of Audit Findings

Audit information that is routinely gathered must be reviewed in a timely manner, currently monthly, by the responsible workforce member(s). On a quarterly basis, logs are reviewed to assure the proper data is being captured and retained. The following process details how log reviews are done at EA:
1. The Security Officer initiates the log review by creating an Issue in the Asana Compliance Review Activity (CRA) Project.
2. The Security Officer, or an EA Security Engineer assigned by the Security Officer, is assigned to review the logs.
3. Relevant audit log findings are added to the Issue; these findings are investigated in a later step. 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. Relevant findings are reviewed at this stage. If the Issue is rejected, it goes back for further review and documentation. The communications protocol around specific findings are outlined below.
5. If the Issue is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
The reporting process shall allow for meaningful communication of the audit findings to those workforce members, Customers, or Partners requesting the audit.
1. Significant findings shall be reported immediately in a written format. EA’s security incident response form may be utilized to report a single event.
2. Routine findings shall be reported to the sponsoring leadership structure in a written report format.
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.
Security audits constitute an internal, confidential monitoring practice that may be included in EA’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 e PHI shall not be included in the reports).
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.
Log review activity is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.

7.4 Auditing Customer and Partner Activity

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 EA and the 3rd party. EA will make every effort to assure Customers and Partners do not gain access to data outside of their own Environments.
If it is determined that the Customer or Partner has exceeded the scope of access privileges, EA’s leadership must remedy the problem immediately.
If it is determined that a Customer or Partner has violated the terms of the agreement or any terms within the PIPEDA regulations, EA must take immediate action to remediate the situation. Continued violations may result in discontinuation of the business relationship.

7.5 Audit Log Security Controls and Backup

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.
All audit logs are protected in transit and encrypted at rest to control access to the content of the logs.
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.
- Separate systems are used to apply the security principle of “separation of duties” to protect audit trails from hackers.
- EA logging servers include Elasticsearch, Logstash, and Kibana (ELK) as part of their baseline configuration to ease reviewing of audit log data. The ELK toolkit provides message summarization, reduction, and reporting functionality.

7.6 Workforce Training, Education, Awareness and Responsibilities

EA workforce members are provided training, education, and awareness on safeguarding the privacy and security of business and ePHI. EA’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. EA 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.

7.7 External Audits of Information Access and Activity

Prior to contracting with an external audit firm, EA 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 agreement;
Assign organizational responsibility for supervision of the external audit firm.

7.8 Retention of Audit Data

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:
- Organizational history and experience.
- Available storage space.
Reports summarizing audit activities shall be retained for a period of six years.
Audit log data is retained locally on the audit log server for a one-month period. Beyond that, log data is encrypted and moved to warm storage (currently S3) using automated scripts, and is retained for a minimum of one year.

7.9 Potential Trigger Events

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

8 Configuration Management Policy

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

8.1 Configuration Management Policies

Chef and Salt are used to standardize and automate configuration management.
No systems are deployed into EA environments without approval of the EA CTO.
All changes to production systems, network devices, and firewalls are approved by the EA CTO before they are implemented to assure they comply with business and security requirements.
All changes to production systems are tested before they are implemented in production.
Implementation of approved changes are only performed by authorized personnel.
Tooling to generate an up-to-date inventory of systems, including corresponding architecture diagrams for related products and services, is hosted on GitHub.
- All systems are categorized as production and utility to differentiate based on criticality.
- The Security Officer maintains scripts to generate inventory lists on demand using APIs provided by each cloud provider.
- These scripts are used to generate the diagrams and asset lists required by the Risk Assessment phase of EA’s Risk Management procedures (see Section 3.2.1).
- After every use of these scripts, the Security Officer will verify their accuracy by reconciling their output with recent changes to production systems. The Security Officer will address any discrepancies immediately with changes to the scripts.
All frontend functionality (developer dashboards and portals) is separated from backend (database and app servers) systems by being deployed on separate servers or containers.
All software and systems are tested using unit tests and end to end tests.
All committed code is reviewed using pull requests to assure software code quality and proactively detect potential security issues in development.
EA utilizes development and staging environments that mirror production to assure proper function.
All formal change requests require unique ID and authentication.
Clocks are continuously synchronized to an authoritative source across all systems using NTP or a platform-specific equivalent. Modifying time data on systems is restricted.

8.2 Provisioning Production Systems

Before provisioning any systems, ops team members must file a request in the Asana Deployment Ticket (DT) project.
- Asana access requires authenticated users.
- The CTO grants access to the Asana DT project following the procedures covered in Section 6.1.
The CTO must approve the provisioning request before any new system can be provisioned.
Once provisioning has been approved, the ops team member must configure the new system according to the standard baseline chosen for the system’s role.
If the system will be used to house production data (ePHI), the ops team member must add an encrypted block data volume to the VM during provisioning.
- For systems on Azure, the ops team member must add an encrypted Elastic Block Storage (EBS) volume.
- For systems on other cloud providers, the ops team member must add a block data volume and set up OS-level data encryption using Salt or Chef.
Once the system has been provisioned, the ops team member must contact the security team to inspect the new system. A member of the security team will verify that the secure baseline has been applied to the new system, including (but not limited to) verifying the following items:
- Removal of default users used during provisioning.
- Network configuration for system.
- Data volume encryption settings.
- Intrusion detection and virus scanning software installed.
- All items listed below in the operating system-specific subsections below.
Once the security team member has verified the new system is correctly configured, the team member must add that system to the Nessus security scanner configuration.
The new system may be rotated into production once the CTO verifies all the provisioning steps listed above have been correctly followed and has marked the Issue with the Approved state.

8.2.1 Provisioning Linux Systems

Linux systems have their baseline security configuration applied via Salt states. These baseline Salt states cover:
- Ensuring that the machine is up-to-date with security patches and is configured to apply patches in accordance with our policies.
- Stopping and disabling any unnecessary OS services.
- Installing and configuring the OSSEC IDS agent.
- Configuring 15-minute session inactivity timeouts.
- Installing and configuring the ClamAV virus scanner.
- Installing and configuring the NTP daemon, including ensuring that modifying system time cannot be performed by unprivileged users.
- Configuring LUKS volumes for providers that do not have native support for encrypted data volumes, including ensuring that encryption keys are protected from unauthorized access.
- Configuring authentication to the centralized LDAP servers.
- Configuring audit logging as described in Section 7.
Any additional Salt states applied to the Linux system must be clearly documented by the ops team member in the DT request by specifying the purpose of the new system.

8.2.2 Provisioning Windows Systems

Windows systems have their baseline security configuration applied via the combination of Group Policy settings and Chef recipes. These baseline settings cover:
- Joining the Windows Domain Controller and applying the Active Directory Group Policy configuration.
- Ensuring that the machine is up-to-date with security patches and is configured to apply patches in accordance with our policies.
- Stopping and disabling any unnecessary OS services.
- Installing and configuring the OSSEC IDS agent.
- Configuring 15-minute session inactivity timeouts.
- Installing and configuring the Avast virus scanner.
- Configuring transport encryption according to the requirements described in Section 16.8.
- Configuring the system clock, including ensuring that modifying system time cannot be performed by unprivileged users.
- Configuring audit logging as described in Section 7.
Any additional Salt states applied to the system must be clearly documented by the ops team member in the DT request by specifying the purpose of the new system.

8.2.3 Provisioning Management Systems

Provisioning management systems such salt servers, LDAP servers, or VPN appliances follows the same procedure as provisioning a production system.
Provisioning the first Salt server for a production pod requires bootstrapping Salt. The CTO will oversee provisioning a new Salt server.
- Once the Salt server has been bootstrapped, the ops team member will apply the baseline configuration to the Salt server by performing a highstate operation as usual.
Critical infrastructure services such as logging, monitoring, LDAP servers, or Windows Domain Controllers must be configured with appropriate Salt states.
- These Salt states have been approved by the CTO to be in accordance with all EA policies, including setting appropriate:
  - Audit logging requirements.
  - Password size, strength, and expiration requirements.
  - Transmission encryption requirements.
  - Network connectivity timeouts.
Critical infrastructure roles applied to new systems must be clearly documented by the ops team member in the DT request.

8.3 Changing Existing Systems

Subsequent changes to already-provisioned systems are unconditionally handled by one of the following methods:
- Changes to Salt states or pillar values.
- Changes to Chef recipes.
- For configuration changes that cannot be handled by Chef or Salt, a runbook describing exactly what changes will be made and by whom.
Configuration changes to Chef recipes or Salt states must be initiated by creating a Merge Request in GitHub.
- The ops team member will create a feature branch and make their changes on that branch.
- The ops team member must test their configuration change locally when possible, or on a development and/or staging sandbox otherwise.
- At least one other ops team member must review the Chef or Salt change before merging the change into the main branch.
In all cases, before rolling out the change to production, the ops team member must file an Issue in the DT project describing the change. This Issue must link to the reviewed Merge Request and/or include a link to the runbook.
Once the request has been approved by the CTO, the ops team member may roll out the change into production environments.

8.4 Patch Management Procedures

EA uses automated tooling to ensure systems are up-to-date with the latest security patches.
On Ubuntu Linux systems, the unattended-upgrades tool is used to apply security patches in phases.
- The security team maintains a mirrored snapshot of security patches from the upstream OS vendor. This mirror is synchronized bi-weekly and applied to development systems nightly.
- If the development systems function properly after the two-week testing period, the security team will promote that snapshot into the mirror used by all staging systems. These patches will be applied to all staging systems during the next nightly patch run.
- If the staging systems function properly after the two-week testing period, the security team will promote that snapshot into the mirror used by all production systems. These patches will be applied to all production systems during the next nightly patch run.
- Patches for critical kernel security vulnerabilities may be applied to production systems using hot-patching tools at the discretion of the Security Officer. These patches must follow the same phased testing process used for non-kernel security patches; this process may be expedited for severe vulnerabilities.
On Windows systems, the baseline Group Policy setting configures Windows Update to implement the patching policy.

8.5 Software Development Procedures

All development uses feature branches based on the main branch used for the current release. Any changes required for a new feature or defect fix are committed to that feature branch.
- These changes must be covered under:
  - unit tests where possible, or
  - integration tests
- Integration tests are required if unit tests cannot reliably exercise all facets of the change.
Developers are strongly encouraged to follow the commit message conventions suggested by GitHub.
- Commit messages should be wrapped to 72 characters.
- Commit messages should be written in the present tense. This convention matches up with commit messages generated by commands like git merge and git revert.
Once the feature and corresponding tests are complete, a pull request will be created using the GitHub web interface. The pull request should indicate which feature or defect is being addressed and should provide a high-level description of the changes made.
Code reviews are performed as part of the pull request procedure. Once a change is ready for review, the author(s) will notify other engineers using an appropriate mechanism, typically via an @channel message in Slack.
- Other engineers will review the changes, using the guidelines above.
- Engineers should note all potential issues with the code; it is the responsibility of the author(s) to address those issues or explain why they are not applicable.
If the feature or defect interacts with ePHI, or controls access to data potentially containing ePHI, the code changes must be reviewed by the Security Officer before the feature is marked as complete.
- This review must include a security analysis for potential vulnerabilities such as those listed in the OWASP Top 10.
- This review must also verify that any actions performed by authenticated users will generate appropriate audit log entries.
Once the review process finishes, each reviewer should leave a comment on the pull request saying “looks good to me” or a message worded similarly, at which point the original author(s) may merge their change into the release branch.

8.6 Software Release Procedures

Software releases are treated as changes to existing systems and thus follow the procedure described in Section 8.3.

9 Facility Access Policy

EA works with Subcontractors to assure restriction of physical access to systems used as part of the EA Platform. EA and its Subcontractors control access to the physical buildings/facilities that house these systems/applications, or in which EA workforce members operate, in accordance with the PIPEDA regulations and its implementation specifications. Physical Access to all of EA 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 EA’s facility.

EA does not physically house any systems used by its Platform in EA facilities. Physical security of our Platform servers is outlined in Section 1.3.

9.1 EA-controlled Facility Access Policies

Visitor and third party support access is supervised. All visitors are escorted.
Fire extinguishers and detectors are installed according to applicable laws and regulations.
Maintenance is controlled and conducted by authorized personnel in accordance with supplier-recommended intervals, insurance policies and the organization’s maintenance program.
Electronic and physical media containing covered information is securely destroyed (or the information securely removed) prior to disposal.
The organization securely disposes media with sensitive information.
Physical access is restricted using.
- Restricted areas and facilities are locked 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.
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 EA.
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 EA are the property of EA and are distributed to users by the company.

10 Incident Response Policy

EA 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

10.1 Incident Management Policies

The EA incident response process follows the process recommended by SANS, an industry leader in security. Process flows are a direct representation of the SANS process.

EA’s incident response classifies security-related events into the following categories:

Events - Any observable computer security-related occurrence in a system or network with a negative consequence. Examples:
- Hardware component failing causing service outages.
- Software error causing service outages.
- General network or system instability.
Precursors - A sign that an incident may occur in the future. Examples:
- Monitoring system showing unusual behavior.
- Audit log alerts indicated several failed login attempts.
- Suspicious emails targeting specific EA staff members with administrative access to production systems.
Indications - A sign that an incident may have occurred or may be occurring at the present time. Examples:
- IDS alerts for modified system files or unusual system accesses.
- Antivirus alerts for infected files.
- Excessive network traffic directed at unexpected geographic locations.
Incidents - A violation of computer security policies or acceptable use policies, often resulting in data breaches. Examples:
- Unauthorized disclosure of ePHI.
- Unauthorized change or destruction of ePHI.
- A data breach accomplished by an internal or external entity.
- A Denial-of-Service (DoS) attack causing a critical service to become unreachable.

EA employees must report any unauthorized or suspicious activity seen on production systems or associated with related communication systems (such as email or Slack). In practice this means keeping an eye out for security events, and letting the Security Officer know about any observed precursors or indications as soon as they are discovered.

10.1.1 Identification Phase

Immediately upon observation EA members report suspected and known Events, Precursors, Indications, and Incidents in one of the following ways:
- Direct report to management, the Security Officer, Privacy Officer, or other;
- Email;
- Phone call;
- Online incident;
- Secure Chat.
- Anonymously through workforce members desired channels.
The individual receiving the report facilitates completion of an Incident Identification form and notifies the Security Officer (if not already done).
The Security Officer determines if the issue is an Event, Precursor, Indication, or Incident.
1. 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 Security Incident Report form 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.
2. 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 an Security Incident Report form or an Incident Survey form. The intent of the Security Incident Report form is to provide a summary of all events, efforts, and conclusions of each Phase of this policy and procedures.
The Security Officer, Privacy Officer, or EA 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.
In the case of a threat identified, the Security Officer is to form a team to investigate and involve necessary resources, both internal to EA and potentially external.

10.1.2 Containment Phase (Technical)

In this Phase, EA’s IT department 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.

The SIRT reviews any information that has been collected by the Security Officer or any other individual investigating the security incident.
The SIRT secures the network perimeter.
The IT department 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 Security Incident Report 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.
Continuously apprise Senior Management of progress.
Continue to notify affected Customers and Partners with relevant updates as needed

10.1.3 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).

Determine symptoms and cause related to the affected system(s).
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.
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.
Complete the Eradication form.
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).
Apprise Senior Management of the progress.
Continue to notify affected Customers and Partners with relevant updates as needed.
Move to Phase IV, Recovery.

10.1.4 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.

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.

10.1.5 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.

Responders to the security incident (SIRT Team and technical security resource) meet to review the documentation collected during the security incident.
Create a “lessons learned” document and attach it to the completed Security Incident Report form.
1. Evaluate the cost and impact of the security incident to EA 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.

10.1.6 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 EA’s expectation for them, relative to security responsibilities. The incident response plan is tested annually.

10.2 Security Incident Response Team (SIRT)

Current members of the EA SIRT:

Security Officer
Privacy Officer
CTO

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

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.)
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.
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.
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.
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.
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.
Methods of Notification: EA Customers will be notified via email within the timeframe for reporting breaches, as outlined above.
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.
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.
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.
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.
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

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.
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:

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 themselves 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 to protect against further breaches.
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,

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

12 Disaster Recovery Policy

The EA Contingency Plan establishes procedures to recover EA following a disruption resulting from a disaster. This Disaster Recovery Policy is maintained by the EA Security Officer and Privacy Officer.

The following objectives have been established for this plan:

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 IT operations and recover damage done to the original system;
- Reconstitution phase to restore IT system processing capabilities to normal operations.
Identify the activities, resources, and procedures needed to carry out EA processing requirements during prolonged interruptions to normal operations.
Identify and define the impact of interruptions to EA systems.
Assign responsibilities to designated personnel and provide guidance for recovering EA during prolonged periods of interruption to normal operations.
Ensure coordination with other EA staff who will participate in the contingency planning strategies.
Ensure coordination with external points of contact and vendors who will participate in the contingency planning strategies.

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.

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

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.
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.

12.1 Line of Succession

The following order of succession to ensure that decision-making authority for the EA Contingency Plan is uninterrupted. The Chief Technology Officer (CTO) is responsible for ensuring the safety of personnel and the execution of procedures documented within this EA Contingency Plan. If the CTO 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.

David Reid, CTO: dreid@effortlessadmin.com
David Ross, CEO: dreid@effortlessadmin.com

12.2 Responsibilities

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

The Ops Team is responsible for recovery of the EA hosted environment, network devices, and all servers. Members of the team include personnel who are also responsible for the daily operations and maintenance of EA. The team leader is the CTO and directs the Dev Ops Team.
The Web Services Team is responsible for ensuring all application servers, web services, and platform features are working. It is also responsible for testing deployments and assessing damage to the environment. The team leader is the CTO and directs the Web Services Team.

Members of the Ops and Web Services teams must maintain local copies of contact information. Additionally, the CTO must maintain a local copy of this policy in the event Internet access is not available during a disaster scenario.

12.3 Testing and Maintenance

The CTO 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 (within 365 days). 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.

12.3.1 Tabletop Testing

The primary objective of the tabletop test is to ensure designated personnel are knowledgeable and capable of performing the notification/activation requirements and procedures 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.

12.3.2 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.

12.4 Disaster Recovery Procedures

12.4.1 Notification and Activation Phase

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

The notification sequence is listed below:

The first responder is to notify the CTO. All known information must be relayed to the CTO.
The CTO is to contact the Web Services Team and inform them of the event. The CTO is to begin assessment procedures.
The CTO 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 CTO is to following the steps below.
- Damage Assessment Procedures:
  - The CTO is to logically assess damage, gain insight into whether the infrastructure is salvageable, and begin to formulate a plan for recovery.
- Alternate Assessment Procedures:
  - Upon notification, the CTO is to follow the procedures for damage assessment with combined Dev Ops and Web Services Teams.
The EA Contingency Plan is to be activated if one or more of the following criteria are met:
- EA 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 EA.
- If the plan is to be activated, the CTO is to notify and inform team members of the details of the event and if relocation is required.
- Upon notification from the CTO, 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 CTO is to notify the hosting facility partners that a contingency event has been declared.
- The CTO is to notify remaining personnel and executive leadership on the general status of the incident.
- Notification can be by message, email, or phone.

12.4.2 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 EA 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 EA infrastructure to a production state.

The tasks outlined 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 - 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

12.4.3 Reconstitution Phase

This section discusses activities necessary for restoring EA 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, EA 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.

Original or New Site Restoration
- Begin replication of new environment - 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
Plan Deactivation
- If the EA 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 EA Media Disposal Policy.

13 Disposable Media Policy

EA 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 provincial law. The schedule for destruction/disposal shall be suspended for ePHI involved in any open investigation, audit, or litigation.

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

13.1 Disposable Media Policy

All removable media is restricted, audited, and is encrypted.
EA assumes all disposable media in its Platform may contain ePHI, so it treats all disposable media with the same protections and disposal policies.
All destruction/disposal of ePHI media will be done in accordance with federal and provincial laws and regulations and pursuant to the EA’s written retention policy/schedule. Records that have satisfied the period of retention will be destroyed/disposed of in an appropriate manner.
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.
Before reuse of any media, for example all ePHI is rendered inaccessible, cleaned, or scrubbed. All media is formatted to restrict future access.
All EA 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.
Any media containing ePHI is disposed using a method that ensures the ePHI could not be readily recovered or reconstructed.
The methods of destruction, disposal, and reuse are assessed periodically, based on current technology, accepted practices, and availability of timely and cost-effective destruction, disposal, and reuse technologies and services.
In the cases of an EA Customer terminating a contract with EA and no longer utilize EA Services, the following actions will be taken depending on the EA Services in use. In all cases it is solely the responsibility of the EA Customer to maintain the safeguards required of PIPEDA once the data is transmitted out of EA Systems. EA will provide the customer with 30 days from the date of termination to export data.

14 Intrusion Detection Policy

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

14.1 Intrusion Detection Policy

OSSEC is used to monitor and correlate log data from different systems on an ongoing basis. Reports generated by OSSEC are reviewed by the Security Officer on a monthly basis.
OSSEC generates alerts to analyze and investigate suspicious activity or suspected violations.
OSSEC 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).
EA firewalls monitor all incoming traffic to detect potential denial of service attacks. Suspected attack sources are blocked automatically.
All new firewall rules and configuration changes are tested before being pushed into production. All firewall and router rules are reviewed every quarter.
EA utilizes redundant firewall on network perimeters.

15 Vulnerability Scanning Policy

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

15.1 Vulnerability Scanning Policy

Vulnerability detection is performed by the EA Security Officer with assistance from the CTO.
Vulnerability scans are performed against all internal IP addresses (servers, VMs, etc) on EA networks.
Frequency of scanning is as follows:
1. on a weekly basis;
2. after every production deployment.
Reviewing vulnerability reports and findings, as well as any further investigation into discovered vulnerabilities, are the responsibility of the EA Security Officer. The process for reviewing Vulnerability reports is outlined below:
1. The Security Officer initiates the review of a Vulnerability Report by creating an Issue in the Asana Compliance Review Activity (CRA) Project.
2. The Security Officer, or an EA Security Engineer assigned by the Security Officer, is assigned to review the Vulnerability Report.
3. If new vulnerabilities are found during review, the process below is used to test those vulnerabilities is outlined below. 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.
5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
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, CTO, and Privacy Officer to see if they are part of the current risk assessment performed by EA.
  1. Those that are a part of the current risk assessment are checked for mitigations.
  2. Those that are not part of the current risk assessment trigger a new risk assessment, and this process is outlined in detail in the EA Risk Assessment Policy.
All vulnerability scanning reports are retained for 6 years by EA. Vulnerability report review is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.
Penetration testing is performed regularly as part of the EA vulnerability management policy.
1. Internal penetration testing is performed quarterly. Below is the process used to conduct internal penetration tests.
  1. The Security Officer initiates the penetration test by creating an Issue in the Asana Compliance Review Activity (CRA) Project.
  2. The Security Officer, or an EA Security Engineer assigned by the Security Officer, is assigned to conduct the penetration test.
  3. Gaps and vulnerabilities identified during penetration testing are reviewed, with plans for correction and/or mitigation, by the EA Security Officer before the Issue can move to be approved.
  4. Once the testing is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further testing and review.
  5. If the Issue is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
2. Penetration tests results are retained for 6 years by EA.
3. Internal penetration testing is monitored on an annual basis using Asana reporting to assess compliance with above policy.
This vulnerability policy is reviewed on a quarterly basis by the Security Officer and Privacy Officer.

16 Data Integrity Policy

EA takes data integrity very seriously. As stewards and partners of EA 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 EA mission of data protection.

Production systems that create, receive, store, or transmit Customer data (hereafter “Production Systems”) must follow the guidelines described in this section.

16.1 Disabling Non-Essential Services

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

16.2 Monitoring Login Attempts

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

16.3 Prevention of Malware on Production Systems

All Production Systems must have McAfee AntiVirus (or equivalent or better virus scanning engine) running, and set to scan on-access, plus a full scan every 2 hours and at reboot to assure not malware is present. Detected malware is evaluated and removed.
Virus scanning software is run on all Production Systems for antivirus protection.
- Hosts are scanned daily for malicious binaries in critical system paths.
- The malware signature database is checked daily and automatically updated if new signatures are available.
- Logs of virus scans are maintained according to the requirements outlined in 16.5.
All Production Systems are to only be used for EA business needs.

16.4 Patch Management

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.
Administrators subscribe to mailing lists to assure up to date on current version of all EA managed software on Production Systems.

16.5 Intrusion Detection and Vulnerability Scanning

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

16.6 Production System Security

System, network, and server security is managed and maintained by the CTO 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.

16.7 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 for potential security incidents.
Ensure EA Customer Production Data is segmented and only accessible to Customer authorized to access data.
All Production Data at rest is stored on encrypted volumes using encryption keys managed by EA. Encryption at rest is ensured through the use of automated deployment scripts referenced in section 8.
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.

16.8 Transmission Security

All data transmission is encrypted end to end using encryption keys managed by EA. Encryption is not terminated at the network endpoint, 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 2048-bit RSA keys, or keys and ciphers of equivalent or higher cryptographic strength (e.g., 256-bit AES session keys in the case of IPsec encryption).
Transmission encryption keys are limited to use for one year and then must be regenerated.
In the case of EA 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.

17 Data Retention Policy

Despite not being a requirement within PIPEDA, EA understands and appreciates the importance of health data retention. EA has created and implemented the following policy to make it easier for Customers to support data retention laws.

Current EA Customers have data stored by EA as a part of the EA Service.
EA stores customer information for a minimum of six years after a Customer ceases to be a Customer, as defined below:
1. ePHI is retained in EA systems in an inactive state to facilitate follow up communications and inquiries.
2. Certain circumstances may require EA to continue communications between the Customer and Covered Entities that were established while the Customer was still active with EA.
3. Records may be retained indefinitely for legal purposes
4. EA uses anonymized and aggregated data for trend analysis and reporting purposes.

18 Employees Policy

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

18.1 Employment Policies

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.
- Current EA training is hosted on EA’s private internal network.
- Employees must complete this training before accessing production systems containing ePHI.
All workforce members are granted access to formal organizational policies, which include the sanction policy for security violations.
The EA Employee Handbook clearly states the responsibilities and acceptable behavior regarding information system usage, including rules for email, Internet, mobile devices, and social media usage.
- Workforce members are required to sign an agreement stating that they have read and will abide by all terms outlined in the EA Employee Handbook, along with all policies and processes described in this document.
- A Human Resources representative will provide the agreement to new employees during their onboarding process.
EA does not allow mobile devices to connect to any of its production networks.
All workforce members are educated about the approved set of tools to be installed on workstations.
All workforce members are educated that all system usage may be tracked at any time for policy compliance
All new workforce members are given PIPEDA training within 30 days of beginning employment. Training includes PIPEDA reporting requirements, including the ability to anonymously report security incidents, and the levels of compliance and obligations for EA and its Customers and Partners.
- Current EA training is hosted on EA’s private internal network.
All remote (teleworking) workforce members are trained on the risks, the controls implemented, their responsibilities, and sanctions associated with violation of policies. Additionally, remote security is maintained through the use of VPN tunnels for all access to production systems with access to ePHI data.
All EA purchased and owned computers are to display this message at login and when the computer is unlocked:

This computer is owned by Effortless Admin Inc. By logging in, unlocking, and/or using this computer you acknowledge you have seen, and follow, these policies (https://effortlessdev.github.io/policies/) and have completed company training. Please contact us if you have problems with this - .
Employees may only use EA 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 in Section 6.7.
- Any workstations used to access production systems must have virus protection software installed, configured, and enabled.
- EA may monitor access and activities of all users on workstations and production systems in order to meet auditing policy requirements (Section 7).
Access to internal EA systems can be requested using the procedures outlined in Section 6.1. All requests for access must be granted by the EA Security Officer.
Request for modifications of access for any EA employee can be made using the procedures outlined in Section 6.1.
Employees are required to cooperate with federal and provincial investigations.
- Employees must not interfere with investigations through willful misrepresentation, omission of facts, or by the use of threats against any person.
- Employees found to be in violation of this policy will be subject to sanctions as described in Section 4.2.3.

18.2 Issue Escalation

EA workforce members are to escalate issues using the procedures outlined in the Employee Handbook. Issues that are brought to the Escalation Team are assigned an owner. The membership of the Escalation Team is maintained by the Chief Executive Officer.

Security incidents, particularly those involving ePHI, are handled using the process described in Section 10.1. If the incident involves a breach of ePHI, the Security Officer will manage the incident using the process described in Section 11.1. Refer to Section 10.1 for a list of sample items that can trigger EA’s incident response procedures; if you are unsure whether the issue is a security incident, contact the Security Officer immediately.

It is the duty of that owner to follow the process outlined below:

Create an Issue in the Asana Compliance Review Activity (CRA) Project.
The Issue is investigated, documented, and, when a conclusion or remediation is reached, it is moved to Review.
The Issue is reviewed by another member of the Escalation Team. If the Issue is rejected, it goes back for further evaluation and review.
If the Issue is approved, it is marked as Done, adding any pertinent notes required.
The workforce member that initiated the process is notified of the outcome via email.

19 Approved Tools Policy

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

19.1 List of Approved Tools

GitHub - GitHub is a paid service built on top of Git, the version control platform. It 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 EA.
Google Apps - Google Apps is used for email and document collaboration.
Office 365 - Office 365 is used for email hosting and document collaboration.
Asana - Asana is used for issue tracking and project planning and to generate artifacts for compliance procedures.
LiveChat - LiveChat is used to facilitate real time online chat with Customers accessing the EA systems.
Slack - Slack is a chat client used by EA workforce members for internal communications between teams.

20 3rd Party Policy

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

20.1 Policies to Assure 3rd Parties Support EA Compliance

EA does not allow 3rd party access to production systems containing ePHI.
All connections and data in transit between the EA Platform and 3rd parties are encrypted end to end.
A standard agreement with Customers 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.
EA has Service Level Agreements (SLAs) with Subcontractors with an agreed service arrangement addressing liability, service definitions, security controls, and aspects of services management.
- Subcontractors must coordinate, manage, and communicate any changes to services provided to EA.
- Changes to 3rd party services are classified as configuration management changes and thus are subject to the policies and procedures described in Section 8; substantial changes to services provided by 3rd parties will invoke a Risk Assessment as described in Section 3.2.1.
- EA utilizes monitoring tools to regularly evaluate Subcontractors against relevant SLAs.
No EA Customers or Partners have access outside of their own environment, meaning they cannot access, modify, or delete anything related to other 3rd parties.
EA does not outsource software development.
EA maintains and annually reviews a list all current Partners and Subcontractors.
- The list of current Partners and Subcontractors is maintained by the EA Privacy Officer, includes details on all provided services (along with contact information).
- The annual review of Partners and Subcontractors is conducted as a part of the security, compliance, and SLA review referenced below.
EA assesses security, compliance, and SLA requirements and considerations with all Partners and Subcontractors. This includes annual assessment of SOC2 Reports for all EA infrastructure partners.
- EA leverages recurring calendar invites to assure reviews of all 3rd party services are performed annually. These reviews are performed by the EA Security Officer and Privacy Officer. The process for reviewing 3rd party services is outlined below:
  1. The Security Officer initiates the SLA review by creating an Issue in the Asana Compliance Review Activity (CRA) Project.
  2. The Security Officer, or Privacy Officer, is assigned to review the SLA and performance of 3rd parties. The list of current 3rd parties, including contact information, is also reviewed to assure it is up to date and complete.
  3. SLA, security, and compliance performance is documented in the Issue.
  4. Once the review is completed and documented, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
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.
Any changes to Partner and Subcontractor services and systems are reviewed before implementation.
For all partners, EA reviews activity annually to assure partners are in line with SLAs in contracts with EA.
SLA review is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.

21 Key Definitions

Application: An application hosted by EA, either maintained and created by EA, or maintained and created by a Customer or Partner.
Application Level: Controls and security associated with an Application. In the case of SaaS Customers, EA does not have access to and cannot assure compliance with security standards and policies at the Application Level.
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.
BaaS: Backend-as-a-Service. A set of APIs, and associated SDKs, for rapid mobile and web application development. APIs offer the ability to create users, do authentication, store data, and store files.
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 names, telephone numbers, fax numbers, email addresses, social insurance numbers, medical record numbers, bank account numbers, certificate numbers, license numbers, Internet Protocol (IP) address numbers, biometric identifiers (including finger and voice prints), full face photographic images, date of birth, and postal 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) 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. Covered Entity: A health plan, healthcare 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 EA Platform.
Electronic Protected Health Information (ePHI): Any individually identifiable health information protected by PIPEDA 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 EA, its operations, or its Customers, though it may be less than optimal. Examples of events include, but are not limited to:
1. A hard drive malfunction that requires replacement;
2. Systems become unavailable due to power outage that is non-hostile in nature, with redundancy to assure ongoing availability of data;
3. 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.
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:
1. 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;
2. The antivirus software alerts when it detects that a host is infected with a worm;
3. Users complain of slow access to hosts on the Internet;
4. The system administrator sees a filename with unusual characteristics;
5. Automated alerts of activity from log monitors;
6. An alert about file system integrity issues.
Intrusion Detection System (IDS): A software tool used 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 Canadian government, a province, a political subdivision of a Province or territory 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.
Offsite: For the purpose of storage of Backup media, offsite 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 EA.
Partner: Contractual bound 3rd party vendor with integration with the EA Platform.
Platform: The overall technical environment of EA.
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:
1. Past, present or future physical or mental health or condition of an individual.
2. The provision of health care to an individual.
3. 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:
1. Suspicious network and host-based IDS events/attacks;
2. Alerts as a result of detecting malicious code at the network and host levels;
3. Alerts from file integrity checking software;
4. 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 PIPEDA Privacy, Security and HITECH policies, procedures, training program, computer system setup, and technical security controls, and who are responsible for the risk management process and procedures outlined below.
Risk Assessment process:
1. 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;
2. Prioritizes risks; and
3. 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.
Risk Mitigation: 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:
1. A system or network breach accomplished by an internal or external entity; this breach can be inadvertent or malicious;
2. Unauthorized disclosure;
3. Unauthorized change or destruction of ePHI (i.e. delete dictation, data alterations not following EA’s procedures);
4. Denial of service not attributable to identifiable physical, environmental, human or technology causes;
5. Disaster or enacted threat to business continuity;
6. 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:
7. Denial of Service: An attack that prevents or impairs the authorized use of networks, systems, or applications by exhausting resources;
8. Malicious Code: A virus, worm, Trojan horse, or other code-based malicious entity that infects a host;
9. 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;
10. Inappropriate Usage: A person violates acceptable computing use policies;
11. 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:
1. Environmental - external fires, HVAC failure/temperature inadequacy, water pipe burst, power failure/fluctuation, etc.
2. Human - hackers, data entry, workforce/ex-workforce members, impersonation, insertion of malicious code, theft, viruses, SPAM, vandalism, etc.
3. Natural - fires, floods, electrical storms, tornados, etc.
4. Technological - server failure, software failure, ancillary equipment failure, etc. and environmental threats, such as power outages, hazardous material spills.
5. 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.
1. Electronic PHI has been encrypted 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).
3. Valid encryption processes for data in motion (i.e. data that is moving through a network, including wireless transmission).
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 such that the PHI cannot be retrieved.
Vendors: Persons from other organizations marketing or selling products or services, or providing services to EA.
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.

Information systems management system

Effortless Admin's security policies and procedures

1. Introduction

1.1 Software as a Service (SaaS)

​1.2​ Compliance

1.3 EA Organizational Concepts

​1.4​ Requesting Audit and Compliance Reports

​1.5​ Version Control

​2​ Policy Management Policy

​2.1​ Maintenance of Policies

​3​ Risk Management Policy

​3.1​ Risk Management Policies

​3.2​ Risk Management Procedures

​3.2.1​ Risk Assessment

​3.2.2​ Risk Mitigation

​3.2.3​ Risk Management Schedule

​3.3​ Process Documentation

​4​ Roles Policy

​4.1​ Privacy Officer

​4.1.1​ Workforce Training Responsibilities

​4.2​ Security Officer

​4.2.1​ Organizational Responsibilities

​4.2.2​ Supervision of Workforce Responsibilities

​4.2.3​ Sanctions of Workforce Responsibilities

​5​ Data Management Policy

​5.1​ Backup Policy and Procedures

​6​ System Access Policy

​6.1​ Access Establishment and Modification

​6.2​ Workforce Clearance

​6.3​ Access Authorization

​6.4​ Person or Entity Authentication

​6.5​ Unique User Identification

​6.6​ Automatic Logoff

​6.7​ Employee Workstation Use

​6.8​ Wireless Access Use

​6.9​ Employee Termination Procedures

​6.10​ Paper Records

6.11​ Password Management

​6.12​ Access to ePHI

​7​ Auditing Policy

​7.1​ Auditing Policies

​7.2​ Audit Requests

​​7.3​ Review and Reporting of Audit Findings

​​7.4​ Auditing Customer and Partner Activity

​​7.5​ Audit Log Security Controls and Backup

​​7.6​ Workforce Training, Education, Awareness and Responsibilities

​​7.7​ External Audits of Information Access and Activity

​​7.8​ Retention of Audit Data

​​7.9​ Potential Trigger Events

​8​ Configuration Management Policy

​8.1​ Configuration Management Policies

​8.2​ Provisioning Production Systems

​8.2.1​ Provisioning Linux Systems

​8.2.2​ Provisioning Windows Systems

​8.2.3​ Provisioning Management Systems

​8.3​ Changing Existing Systems

​8.4​ Patch Management Procedures

​8.5​ Software Development Procedures

​8.6​ Software Release Procedures

9​ Facility Access Policy

​9.1​ EA-controlled Facility Access Policies

​10​ Incident Response Policy

​10.1​ Incident Management Policies

​10.1.1​ Identification Phase

​10.1.2​ Containment Phase (Technical)

​10.1.3​ Eradication Phase (Technical)

​10.1.4​ Recovery Phase (Technical)

​10.1.5​ Follow-up Phase (Technical and Non-Technical)

​10.1.6​ Periodic Evaluation

​10.2​ Security Incident Response Team (SIRT)

11​ Breach Policy

​11.1​ EA Breach Policy

​11.2​ EA Platform Customer Responsibilities

​11.3​ Sample Letter to Customers in Case of Breach

​12​ Disaster Recovery Policy

​12.1​ Line of Succession

​12.2​ Responsibilities

​12.3​ Testing and Maintenance

​12.3.1​ Tabletop Testing

​12.3.2​ Technical Testing