What You Need to DO

Implementation and development of a written, comprehensive security program and establishment of a security system covering businesses' computers are at the heart of the standards. The standards provide a detailed list of comprehensive security system and security system requirements.

Comprehensive, Written Information Security Program

Section 17.03 of the standards requires covered entities to "develop, implement, maintain and monitor a comprehensive, written information security program ("program") applicable to any records containing" protected information which is consistent with industry standards. A program must contain "administrative, technical, and physical safeguards to ensure the security and confidentiality" of the records. Additionally, such safeguards must be consistent with the requirements established by any state or federal standards by which a given organization may be regulated.

The standards specify mandatory minimum requirements to every program. Each program shall:

• Designate one or more employees to maintain the program;
• Identify and assessing reasonably foreseeable internal and external risks to the security, confidentiality and integrity of the records containing personal information and—evaluating and improving—the effectiveness of the current safeguards for limiting such risks;
• Develop security policies for employees as to whether and how employees should be allowed to keep, access and transport records containing personal information outside of business premises;
• Impose disciplinary measures for violation of the program;
• Prevent terminated employees from accessing records containing personal information by immediately terminating their access to such records;
• Take reasonable steps to verify that third-party service providers with access to personal information have the capacity to protect such personal information;
• Limit the amount of personal information collected to that reasonably necessary to accomplish a legitimate purpose for which it is collected; limiting the time such information is retained to that reasonably necessary to accomplish such purpose; and limiting access to such persons who are reasonably required to know such information in order to accomplish such purpose or to comply with state or federal record retention requirements;
• Identify records and devices used to store personal information, to determine which records contain personal information;
• Place reasonable restrictions upon physical access to records containing personal information;
• Monitor regularly to ensure that the program is operating in a manner reasonably calculated to prevent unauthorized access to or unauthorized use of personal information; and upgrading information safeguards as necessary to limit risks;
• Review the scope of the security measures at least annually or whenever there is a material change in business practices that may reasonably implicate the security of records containing personal information;
• Document responsive actions taken in connection with any incident involving a breach of security or integrity of records.