Breach Investigation and Notification
| Title | Breach Investigation and Notification |
| Doc# | POL-COMP-006 |
| Version | 1.0 |
| Date | 20-10-2023 |
To provide guidance for breach notification when impressive or unauthorised access, acquisition, use and/or disclosure of the ePHI occurs. In the case of a breach, CloudCore shall notify all affected Customers. It is the responsibility of the Customers to notify affected individuals.
Policy Statements
CloudCore policy requires that:
Breach notification procedures are invoked upon confirmation of security breach that results in unauthorised disclosure of unprotected/unencrypted sensitive data.
Individuals impacted by a confirmed data breach must be notified within 60 days of discovery of such breach.
In the event of a data breach that involves unencrypted ePHI, CloudCore must report the breach to individuals impacted following the HIPAA Breach Notification requirements (45 CFR Part 164, Subpart D).
Controls and Procedures
Breach Investigation Process
Discovery of Breach: A data breach shall be treated as “discovered” as of the first day on which such breach is known to the organisation, or, by exercising reasonable diligence would have been known to CloudCore (includes breaches by the organisation’s Customers, Partners, or subcontractors). CloudCore 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 organisation. Following the discovery of a potential breach, the organisation shall begin an investigation (see organisational 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. CloudCore shall also begin the process of determining what external notifications are required or should be made (e.g., Secretary of Department of Health & Human Services (HHS), media outlets, law enforcement officials, etc.)
Breach Investigation: The CloudCore 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 organisation as appropriate (e.g., administration, security incident response team, human resources, risk management, public relations, legal counsel, etc.) The investigator shall be the key facilitator for all breach notification processes to the appropriate entities (e.g., HHS, media, law enforcement officials, etc.). All documentation related to the breach investigation, including the risk assessment, shall be retained for a minimum of seven years. A breach log is kept and maintained by the Security and Privacy Officer.
Risk Assessment: A risk assessment is performed in accordance to applicable laws and regulations.
For an acquisition, access, use or disclosure of ePHI to constitute a breach, it must constitute a violation of the HIPAA Privacy Rule. A use or disclosure of ePHI that is incident to an otherwise permissible use or disclosure and occurs despite reasonable safeguards and proper minimum necessary procedures would not be a violation of the Privacy Rule and would not qualify as a potential breach. To determine if an impermissible use or disclosure of ePHI constitutes a breach and requires further notification, the organisation 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 organisation shall document the risk assessment as part of the investigation in the incident report form noting the outcome of the risk assessment process. The organisation 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 organisation 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 impermissibility used or to whom the information was impermissibility disclosed;
- The type and amount of ePHI involved;
- The cause of the breach, and the entity responsible for the breach, either Customer, CloudCore, or Partner.
- The potential for significant risk of financial, reputation, or other harm.
Timeliness of Notification: Upon discovery of a breach, notice shall be made to the affected CloudCore Customers, usually within 24-48 hours but no later than 10 calendar days after the discovery of the breach. It is the responsibility of the organisation to demonstrate that all notifications were made as required, including evidence demonstrating the necessity of delay.
Delay of Notification Authorised for Law Enforcement Purposes: If a law enforcement official states to the organisation that a notification, notice, or posting would impede a criminal investigation or cause damage to national security, the organisation shall:
- If the statement is in writing and specifies the time for which a delay is required, delay such notification, notice, or posting of the timer period specified by the official; or
- If the statement is made orally, document the statement, including the identify of the official making the statement, and delay the notification, notice, or posting temporarily and no longer than 30 days from the date of the oral statement, unless a written statement as described above is submitted during that time.
Content of the Notice: The notice shall be written in plain language and must contain the following information:
- A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known;
- A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known;
- Any steps the Customer should take to protect Customer data from potential harm resulting from the breach.
- A brief description of what CloudCore 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: CloudCore Customers will be notified via email and phone within the time frame for reporting breaches, as outlined above.
Maintenance of Breach Information/Log: As described above and in addition to the reports created for each incident, CloudCore shall maintain a process to record or log all breaches of unsecured sensitive data regardless of the number of records and Customers affected. The following information should be collected/logged for each breach (see sample Breach Notification Log):
- A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
- A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
- A description of the action taken with regard to notification of patients regarding the breach.
- Resolution steps taken to mitigate the breach and prevent future occurrences.
Workforce Training: CloudCore shall train all members of its workforce on the policies and procedures with respect to sensitive data 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 organisation.
Complaints: CloudCore must provide a process for individuals to make complaints concerning the organisation’s patient privacy policies and procedures or its compliance with such policies and procedures.
Sanctions: The organisation 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: CloudCore 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 organisation may not require individuals to waive their privacy rights under as a condition of the provision of treatment, payment, enrolment in a health plan, or eligibility for benefits.
CloudCore Platform Customer Responsibilities
The following requirements and guidelines shall be provided to and agreed upon by a client organisation using CloudCore platform to host sensitive data such as ePHI and PII.
The agreement may be in the form of a contract or acceptance of terms and conditions.
The CloudCore Customer that accesses, maintains, retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses unsecured sensitive data shall, without unreasonable delay and in no case later than 72 hours after discovery of a breach, notify CloudCore of such breach. The Customer shall provide CloudCore 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 Security number, date of birth, home address, account number, etc.), if known.
- A description of the action taken with regard to notification of patients regarding the breach.
- Resolution steps taken to mitigate the breach and prevent future occurrences.
Depending on the nature of the breach, an investigation may be conducted by CloudCore or the Customer or jointly to determine the cause of breach.
Notice to Media: Unless CloudCore is directly at fault for the cause of breach, CloudCore Customers are responsible for providing notice to prominent media outlets at the Customer’s discretion.
Notice to Authorities: Unless CloudCore is directly at fault for the cause of breach, CloudCore Customers are responsible for providing notice to the appropriate authorities, including the Secretary of Health and Human Services (HHS) and your Lead Supervisory Authority (LSA) under GDPR, at the Customer’s discretion.
Sample Letter to Customers in Case of Breach
[Date]
[Name]
[Name of Customer]
[Address 1]
[Address 2]
[City, State Zip Code]
Dear [Name of Customer]:
I am writing to you from CloudCore, with important information about a recent
breach that affects your account with us. We became aware of this breach on
[Insert Date] which occurred on or about [Insert Date]. The breach occurred as
follows:
Describe event and include the following information:
* A brief description of what happened, including the date of the breach and the
date of the discovery of the breach, if known.
* A description of the types of unsecured protected health information that were
involved in the breach (such as whether full name, Social Security number,
date of birth, home address, account number, diagnosis, disability code or
other types of information were involved), if known.
* Any steps the Customer should take to protect themselves from potential harm
resulting from the breach.
* A brief description of what CloudCore 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,
Sec Urity
Security Officer
CloudCore