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September 2013

Navy Yard Shooting Highlights Effect of Cuts to Navy Security

Security professionals around the entire were shocked and dismayed when they turned on the news and saw the historic Washington Navy Yard locked down, surrounded by emergency vehicles, and looking for an active shooter.

All the shock, the outrage, the Defense Department reaction, the involvement of the overlapping law enforcement jurisdictions, has apparently been already forgotten by the public, moved to the virtual ‘old story’ pile by the latest news of a mall shooting in Kenya, meeting at the UN, and the politics as usual in Washington DC.

If you graph it online, you can see the dramatic spike and then the dramatic drop-off in interest by the general public. This highlights what the security community has to deal with, in the context of a 24 hour news cycle.

My perspective on the event was personal because one of my very best friends was in Building 197 that day, a former navy commander, now a contractor, who went to work at 5 am that morning, and finally returned home at 9 pm that night.  Unlike many shootings, the PCs, smartphones were all up and operational during the event, so people were instantly able to communicate with friends and relatives as the event unfolded.

NavyYard-smallRumors ran rampant that it was terrorism related, that there were three shooters, then that rumor switched to two shooters and eventually to only one shooter, Alexis Aaron, a mentally disturbed young man who had previous events of gun violence and yet had a top secret security clearance at the time of the shooting.

If we took a poll three weeks ago and asked people which facility would they judge to be the safest, the results
would probably look something like this:

1. Military Base in the U.S.
2. Hospital
3. Regional Mall
4. Police Station

Unfortunately – this is more like a list of the places where a shooting is more likely to take place.  As all the work in workplace violence statistics shows, a domestic Military Base has been the site of two mass shootings in only the last 4 years.  This includes the twelve killed and eight wounded at the Washington Navy Yard, as well as the thirteen killed and twenty injured at the Fort Hood shooting in late 2009.  That’s an average of 6 killed each year, and 8 injured, and doesn’t take into account any random shootings, training-related injuries, only the mass shootings.

Hospitals have increased in violent incidents every year for the last ten years, and we just witnessed a mass shooting at a Kenyan Mall.

However, the hospital and the mall are both completely OPEN, they want people to come in, they don’t control access at all.
This is what is so surprising about the Navy Yard shootings, the lack of security, lack of enough armed guards, lack of current background checks, lack of metal detectors, lack of retina scanners, and every other usual form of security control.

Speculation is that the key controls were missing because of budget cuts, which means that the Navy made the decision to reduce security controls, instead of cutting other, less critical programs.  The incident makes a strong case for examining the potential Return on Investment for security controls!

Even if the shooter’s background check was “current”, it certainly had not been updated based on his own recent events, and brushes with the police, and, of course, the anger and mental health problems appears again, and is shrugged off as too tough to manage and track.

However, it is a wake up call for the U.S. Navy, the Department of Defense, the U.S. Capital Police, and a variety of other organizations who “Secure” the Washington DC Capitol zone, and it leads to more questions than answers.

Already, the questions are starting about what controls SHOULD be in place for all military bases, and, naturally, re-examining the background check process and how it could be updated and improved.

Let’s not forget this time.

 

 

 

 



Last-Minute HIPAA Compliance Tips

With only 2 weeks (15 days) left to meet the HIPAA Omnibus Rule, let’s say you
have done everything you could possibly do, to be in full compliance with every
part of HIPAA:

1. Finish a current HIPAA Risk Analysis – CHECK

2. Rewrite Business Associate agreements – CHECK

3. Rewrite Policies & Procedures – CHECK

4. Get PHI off the office copiers – CHECK

5. Gather Documentation in one place – CHECK

6. Start HIPAA Security Awareness Program – CHECK

7. Update HR Sanctions Policies – CHECK

8. Finalize Contingency Plans – CHECK

9. Add more encryption – CHECK

10. Implement Plan for Smartphones & Mobile Devices – CHECK

11. Have staff sign new Affirmation Agreements – CHECK

And in spite of your careful preparation, you walk into work on Monday, and the OCR
regulators are sitting in the Lobby, and they’ve been there since 7:00 AM!

No matter what else you have done, or started, and have not done, your insurance policy is to be
able to pull out your most current (in months, not years) HIPAA Risk Analysis and then pull out all
your supporting documentation including:

1. All information, including network diagrams, on where the PHI is on your network, and the
automated network controls you have implemented.

2. A record of every application, every database, etc. that hold PHI, are used to create,
manage, or share PHI, in both electronic and paper form.

2. Rosters going back 3 years of everyone in the organization who’s taken HIPAA training.

3. A copy of the Policies and Procedures, and Security Plans, printed out and labeled in 3-ring
Binders.

4. List of all HIPAA controls that are currently in place and verification documents.

5. Copies of all Business partners agreements and contracts

6. A notarized statement signed by the Board Director, CEO or Administrator formally
stating the organization’s Commitment to HIPAA Security & Privacy & Omnibus Rules.

7. Copies of recent employee surveys validating their stated compliance with all HIPAA
Security, Privacy, and Omnibus Rules.

All of these elements should be printed in their most current versions and put in D-Ring
binders, which you will pull out of a cabinet designed for high security.  Nothing thrills a regulator
or auditor more than getting everything you ask for in a neatly labeled, giant 3-ring binder.
It says “PREPARED” in a way that having files on the network never will.

And, BTW, you HAVE completed all these steps – right?

For More Information, Contact Caroline Hamilton at caroline@riskandsecurityllc.com



What Happens if OCR Shows up – Asking about your HIPAA Compliance?

With only 2 weeks (15 days) left to meet the HIPAA Omnibus Rule, let’s say you have
done everything you could 
possibly do, to be in full compliance with every part of HIPAA:

1.  Finish a current HIPAA Risk Analysis – CHECK
2.  Rewrite Business Associate agreements – CHECK
2.  Rewrite Policies & Procedures – CHECK
3.  Get PHI off the office copiers – CHECK
4.  Gather Documentation in one place – CHECK
5.  Start HIPAA Security Awareness Program – CHECK
6.  Update HR Sanctions Policies – CHECK
7.  Finalize Contingency Plans – CHECK
8.  Add more encryption – CHECK
9.  Implement Plan for Smartphones & Mobile  Devices – CHECK
10. Have staff sign new affirmation Agreements – CHECK

And in spite of your careful preparation, you walk into work on Monday, and the regulators from
OCR are sitting in the Lobby, and they’ve been there since 7:00 AM!

No matter what else you have done, or started, and have not done, your insurance policy is to be
able to pull out your most current (in months, not years) HIPAA Risk Analysis and then pull out all
your supporting documentation including:

1. All information, including network diagrams, on where the PHI is on your network, and the automated
network controls you have implemented.

2.  A record of every application, every database, etc. that hold PHI, are used to create, manage, or
share PHI, in both electronic and paper form.

2.  Rosters going back 3 years of everyone in the organization who’s taken HIPAA training.

3.  A copy of the Policies and Procedures, and Security Plans, printed out and labeled in 3-ring
Binders.

4.  List of all HIPAA controls that are currently in place and verification documents.

5.  Copies of all Business partners agreements and contracts

6.  A notarized statement signed by the Board Director, CEO or Administrator re-stating
the organization’s Commitment to HIPAA Security & Privacy & Omnibus Rules..

7.  Copies of recent employee surveys validating their stated compliance with all HIPAA
Security,  Privacy, and Omnibus rules.

All of these elements should be printed in their most current versions and put in D-Ring
binders, which you will pull out of a cabinet designed for high security.  Nothing thrills a regulator
or auditor more than getting everything you ask for in a neatly labeled, giant 3-ring binder.

It says “PREPARED”  in a way that having files on the network never will.

And, BTW, you HAVE completed all these steps – right?

 

 

 

 



HIPAA COUNTDOWN – 26 DAYS LEFT TO COMPLY WITH HIPAA OMNIBUS RULE!

The HIPAA Countdown continues, with the HIPAA Omnibus Rule compliance date of September 23rd looming in the distance.

Now that everyone is coming back to work, relaxed from the long weekend (we hope), it’s time to get back to work.

As a HIPAA Risk Analysis expert, I have gotten more than 300 calls and emails in the last 5 days (yes, even on Sunday) about
what NEEDS to be done right now.   Here’s a sample of the questions,

“Should I do a penetration test before Sept 23rd?”
“Should we update our policies before Sept. 23rd?”
“Should I hurry and get the laptops encrypted by Sept 23rd?” 
“We re-wrote our business agreements – what else do I need to do before Sept. 23rd?

To quote Leon Rodriguez, the Director of the Department of Health and Human Services, Office of Civil Rights, which is
the lead federal agency for HIPAA Enforcement, “The Number One Thing you need to do before September 23rd
is to update, or start a new 
HIPAA Risk Analysis.”  

According to the OCR Guideline on Risk Analysis,  “Conducting a risk analysis is the first step in identifying and
implementing safeguards that comply with and carry out the standards and implementation specifications in the Security
Rule. Therefore, a risk analysis is foundational, and must be understood in detail before OCR can issue meaningful
guidance that specifically addresses safeguards and technologies that will best protect electronic health information.”

This is why the First Area that OCR will address when they visit is:  “Where is your HIPAA Risk Analysis?”

Where is yours?  And has it been updated lately?

And did you know that Leon Rodriguez is on Twitter!  His twitter handle is @OCRLeon.

 

 

 




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