Security Management Process Policy (UBIT HIPAA)

Category: HIPAA Security
Responsible Office: UBIT HIPAA Compliance
Responsible Executive: Vice President and Chief Information Officer (VPCIO)
Approved By (Name/Title): J. Brice Bible, VPCIO

CATEGORY: Notification to Individuals
TYPE: Standard
CITATION: 45 CFR 164.308(a)(1)(i)

The University at Buffalo Information Technology (UBIT) operates as a covered entity as defined by the U.S. Department of Health and Human Services Office of Civil Rights (OCR). HIPAA Regulation Text 45 CFR Part 164.308(a)(1)(i) requires a covered entity to implement policies and procedures to prevent, detect, contain, and correct security violations.

UBIT takes reasonable steps to ensure the confidentiality, integrity, and availability of ePHI by implementing appropriate and reasonable policies, procedures, and controls to prevent, detect, contain, and correct information security violations.

This policy applies to all UBIT workforce members.

Workforce members: Adhere to all policies and procedures as written. 

HIPAA Security and Privacy Officer: Takes reasonable steps to ensure the confidentiality, integrity, and availability of ePHI by implementing appropriate and reasonable policies, procedures, and controls to prevent, detect, and correct security violations.

Compliance Officer: Participates in ensuring the security of ePHI is enforced and is effective. Performs this duty in conjunction with the HIPAA Security and Privacy Officer. 

PHI Guardians: Workforce members who are authorized to create or store ePHI or who are responsible for distributed or multi-user systems that are used to store or transmit ePHI have the following security management responsibilities:

1. Protecting the confidentiality, integrity, and availability of ePHI for which they are responsible.
2. Identifying and approving the use of security policies, procedures, and controls for the ePHI for which they are responsible.
3. Authorizing access appropriately to the ePHI for which they are responsible to UBIT’s workforce members.
   
4. Immediately reporting risks, security incidents and violations of UBIT’s policies, procedures, and controls relating to the ePHI for which they are responsible.
5. Supporting investigations of security violations with respect to the ePHI for which they are responsible.
6. Attending appropriate UBIT security training.
   

Data Users: Users of UBIT’s data processing services, such as application software, networks and operating systems are referred to as data users. The security management responsibilities of data users include:

1. Using UBIT data processing resources that contain ePHI only for appropriate purposes and consistent with their approved level of access and authorization.
2. Being aware of and using UBIT-approved security controls.
3. Complying with appropriate UBIT security policies, procedures and standards.
4. Immediately reporting any security violation to the HIPAA Security and Privacy Officer.
5. Attending appropriate UBIT security training as directed by supervisors.
   

Date Approved: 12/6/2017