Security service contractor that consults with businesses that are considered “covered entities” under HIPAA in the U.S.

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Your company is a security service contractor that consults with businesses that are considered “covered entities” under HIPAA in the U.S. who require assistance in compliance with HIPAA. You advertise a proven track record in providing information program security management, information security governance programs, risk management programs, and regulatory and compliance recommendations. You identify vulnerabilities, threats, and risks for clients with the end goal of securing and protecting applications and systems within their organization.

Your client is Health Coverage Associates, a health insurance exchange in California and a covered entity. Because of the Patient Protection and Affordable Care Act (ACA), the exchange enables individuals and small businesses to purchase health insurance at federally subsidized rates. In the past 6 months, they have experienced:

• Vulnerability #1: A malware attack (i.e., SQL Injection) on a critical software application that processed and stored client Protected Health Information (PHI) allowing access to PHI stored within the database
• Vulnerability #2: An internal mistake by an employee that allowed PHI to be emailed to the wrong recipient who was not authorized access to the PHI
• Vulnerability #3: An unauthorized access to client accounts through the company’s login website via the cracking of weak passwords

The selection of security controls will go into the Security Assessment Plan (SAP) covered in Week Three. The SAP will address the required safeguards to protect the confidentiality, integrity, and availability of sensitive data from the attacks listed above and protect their assets from the vulnerabilities that allowed the attacks to occur.

The NIST HIPAA Security Toolkit Application, developed by the National Institute of Standards and Technology (NIST), is intended to help organizations better understand the requirements of the HIPAA Security Rule (HSR), implement those requirements, and assess those implementations in their operational environment. Target users include, but are not limited to, HIPAA covered entities, business associates, and other organizations such as those providing HIPAA Security Rule implementation, assessment, and compliance services.

Sample Solution

HIPAA Security Assessment and Gap Analysis for Health Coverage Associates

Executive Summary

Health Coverage Associates (HCA), a California health insurance exchange covered by HIPAA, has experienced three security incidents within the past six months: a malware attack (SQL injection), an internal email breach, and unauthorized website access due to weak passwords. These incidents expose vulnerabilities in HCA’s security posture and necessitate a comprehensive assessment and gap analysis to ensure compliance with the HIPAA Security Rule (HSR). This report identifies specific control deficiencies, recommends corrective actions, and outlines a roadmap for achieving HIPAA compliance based on the NIST HIPAA Security Toolkit Application.

Vulnerability Assessment and Gap Analysis

Vulnerability #1: Malware Attack (SQL Injection)

  • Control Deficiency: Inadequate access controls and input validation mechanisms for the critical application storing PHI.
  • Gap Analysis: HCA lacks role-based access control (RBAC), multi-factor authentication (MFA), and proper input validation procedures, allowing unauthorized access and malicious code injection.
  • Corrective Actions: Implement RBAC, MFA, and secure coding practices like prepared statements to prevent injection attacks. Conduct regular penetration testing and vulnerability scans to identify and address future weaknesses.

Vulnerability #2: Internal Email Breach

  • Control Deficiency: Insufficient employee training and awareness regarding PHI handling and secure email practices.
  • Gap Analysis: HCA lacks a robust security awareness program and fails to enforce email encryption and access control policies for PHI.
  • Corrective Actions: Develop and implement a comprehensive security awareness program for all employees, emphasizing PHI protection and proper email protocols. Enforce email encryption for all PHI communications and restrict access based on the “need-to-know” principle.

Vulnerability #3: Unauthorized Website Access

  • Control Deficiency: Weak password policies and inadequate website security measures.
  • Gap Analysis: HCA’s password policy is likely simple (e.g., minimum length) and doesn’t enforce password complexity requirements. Website security lacks measures like intrusion detection/prevention and secure session management.
  • Corrective Actions: Implement a strong password policy with complexity requirements, regular password changes, and MFA. Fortify website security with firewalls, intrusion detection/prevention systems, and secure session protocols like HTTPS with TLS/SSL.

Actionable Recommendations

  1. Develop a Security Assessment Plan (SAP): This plan should detail the identified vulnerabilities, risk assessments, and planned corrective actions aligned with the NIST HIPAA Security Toolkit Application. Prioritize high-risk vulnerabilities and address them first.
  2. Implement Administrative Safeguards: Establish comprehensive policies and procedures for PHI handling, access control, password management, incident response, and disaster recovery. Conduct regular risk assessments and workforce training.
  3. Implement Physical Safeguards: Secure physical systems and access points, monitor physical access, and implement data encryption at rest and in transit.
  4. Implement Technical Safeguards: Deploy firewalls, intrusion detection/prevention systems, and antivirus software. Secure your network, implement strong authentication protocols, and regularly patch systems.
  5. Continuous Monitoring and Improvement: Regularly monitor security logs, conduct penetration testing, and update risk assessments. Foster a culture of security awareness and continuous improvement within HCA.

Conclusion

By addressing the identified vulnerabilities and implementing the recommended actions, HCA can significantly improve its security posture and achieve compliance with the HIPAA Security Rule. This will mitigate future security incidents, protect sensitive client data, and maintain trust with individuals and businesses relying on HCA’s services.

Next Steps

  1. Collaborate with HCA leadership to prioritize and schedule corrective actions based on the SAP.
  2. Provide technical assistance and guidance for implementing recommended security controls.
  3. Conduct ongoing monitoring and assessment to ensure HCA maintains a secure and compliant environment.

This report serves as a starting point. We are committed to supporting HCA in achieving and sustaining HIPAA compliance, protecting its valuable assets, and safeguarding the PHI of its clients.

 

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