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Accountable's Policy and Procedure templates are general templates, some of which need updating to fit your company's unique context.

Policy & Procedure Editing Guide

Below are the minimum necessary updates required for our Policy & Procedure templates. Additional updates that are not explicitly defined below may be required, depending on your organization.

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Please read all Policies & Procedures before publishing. Accountable's Policy & Procedure templates are general templates, and need updating to reflect your unique organization's setup and needs.

Policy or Procedure Name	Category	Policy Type	Editing Required
Acceptable Use Policy	Personnel	Acceptable Use	n/a
Access Rights	Technical Safeguards	Access Rights	n/a
Audit Controls; System Alerts	Technical Safeguards	Audit Controls	n/a
Authentication Controls	Technical Safeguards	Authentication Controls	Update the Password Policy requirements to align with what your organization can and will uphold, without compromising on being security conscious
Business Associate Relationship	Risk Management	Business Associate Relationship	n/a
Comprehensive Information Security Plan	Personnel	Information Security Plan	Designating the IT Director, IT Staff, Network Administrator, and Security Administrators Documenting multiple Definitions Policy Effective Date
Confidentiality Agreement	Personnel	Confidentiality Agreement	n/a
Data Backup and Storage	Physical Safeguards	Data Backup	n/a
Data Integrity	Data Management	Data Integrity	List of Critical Systems
De-identification Policy	Technical Safeguards	De Identification	n/a
Device, Media, and Hardware Controls	Physical Safeguards	Device Medial Controls	n/a
Disaster Recovery	Security Incident	Disaster Recovery	List Critical Services List Key Tasks Define SLAs List team members who should be notified during key Disaster Recovery Plan milestones Define key team member's Disaster Recovery Plan roles Set a Recovery Time Objective Write out your organization specific Disaster Recovery Plan steps
Documentation, Records Retention, and Documentation Destruction	Data Management	Documentation	n/a
Encryption	Technical Safeguards	Encryption	If Encryption tool was implemented: Document which tool and how it encrypts data If Encryption tool was not implemented: Document why not If Technology Company: Hosting PHI in the Cloud: document how your provider is encrypting data Hosting PHI locally: ensure data is encrypted and document how
Enforcement Sanctions	Security Incident	Enforcement Sanctions	n/a
Facility Access Controls	Physical Safeguards	Facility Access	Work from Office only... This policy should be updated to reflect the security measures that your organization has in place in the office, clinic, etc. Any ability for team members to access work outside of the office... This policy should be updated to include a section that defines security measures for when people are accessing work outside of the office Examples: cannot use public wifi, must use VPN, etc.
Incident Reporting Policy	Security Incident	Incident Reporting	n/a
Marketing and Fundraising	Personnel	Marketing Fundraising	n/a
Mitigation	Risk Management	Mitigation	n/a
Non-retaliation and Waiver	Personnel	Non Retaliation	n/a
Notification of Breach	Security Incident	Breach Notification	Define a Breach Response Contact
Ongoing Risk Assessment	Risk Management	Risk Assessment	n/a
Personnel Designations	Personnel	Personnel Designations	Enter the Privacy Officer and their phone number Note who can interface with PHI internally
Privacy Policy	Personnel	Privacy	Update the Effective Date
Restricted Internal Access to PHI	Personnel	Restricted PHI Access	n/a
Sanctions Non Compliance	Personnel	Non Compliance Sanctions	n/a
Security Incident Response	Security Incident	Security Incident Response	n/a
Termination Procedures	Personnel	Termination Procedures	n/a
The Minimum Necessary Requirement	Personnel	Minimum Necessary Requirement	n/a
Transmission Security	Technical Safeguards	Transmission Security	n/a
Viruses and Malware; Application Updates	Technical Safeguards	Malware Policy	Document which Anti-Malware System is in place (OS specific or third party)
Workstation Security	Physical Safeguards	Workstation Security	n/a

Policy & Procedure Next Steps Guide

Below are the actions implied by or required to be in compliance with our out-of-the-box Policy & Procedure Templates. Additional action items that are not explicitly defined below may be required, depending on your Policy & Procedure updates and depending on your organization.

Policy or Procedure Name	Category	Policy Type	Action Items
Acceptable Use Policy	Personnel	Acceptable Use	n/a
Access Rights	Technical Safeguards	Access Rights	Assignment of User IDs
Audit Controls; System Alerts	Technical Safeguards	Audit Controls	Setup Audit Logs for all Systems Set up Security Alerts Etc.
Authentication Controls	Technical Safeguards	Authentication Controls	Update Password Policy
Business Associate Relationship	Risk Management	Business Associate Relationship	Have signed BAAs in place for all BAs Note: Accountable has BAA templates, supports e-signature collection, and BAA storage.
Comprehensive Information Security Plan	Personnel	Information Security Plan	n/a
Confidentiality Agreement	Personnel	Confidentiality Agreement	Have signed Confidentiality Agreements (CA) in place for all team members Note: Accountable has CA templates, supports e-signature collection, and CA storage.
Data Backup and Storage	Physical Safeguards	Data Backup	Setup daily backups for Critical Systems Note: “Critical System” means any Company System that regularly processes or stores (a) member information of any type (including ePHI); (b) sensitive employee information; or (c) sensitive business information.
Data Integrity	Data Management	Data Integrity	n/a
De-identification Policy	Technical Safeguards	De Identification	n/a
Device, Media, and Hardware Controls	Physical Safeguards	Device Medial Controls	Document your Data Inventory Note: Accountable supports Data Inventory Documentation
Disaster Recovery	Security Incident	Disaster Recovery	Complete a bi-annual Continuity Plan rehearsal
Documentation, Records Retention, and Documentation Destruction	Data Management	Documentation	n/a
Encryption	Technical Safeguards	Encryption	Decide if an Encryption solutions is appropriate If not, document why not For Technology Companies... Hosting PHI in the Cloud: document how your provider is encrypting data Hosting PHI locally: ensure data is encrypted and document how
Enforcement Sanctions	Security Incident	Enforcement Sanctions	n/a
Facility Access Controls	Physical Safeguards	Facility Access	n/a
Incident Reporting Policy	Security Incident	Incident Reporting	Have all team members acknowledge How to Report an Incident 2x per year Test the Incident Reporting Procedure 2x per year Check for new Incident Reports at least 1x per month
Marketing and Fundraising	Personnel	Marketing Fundraising	n/a
Mitigation	Risk Management	Mitigation	n/a
Non-retaliation and Waiver	Personnel	Non Retaliation	n/a
Notification of Breach	Security Incident	Breach Notification	Review this Policy annually and after each reported Incident Train all Team Members on What a HIPAA Incident is and How to Report Incidents Note: Accountable's HIPAA Training course covers "What is a HIPAA Incident?" Note: Accountable supports Incident Reporting and Training team members how to Report Incidents
Ongoing Risk Assessment	Risk Management	Risk Assessment	Complete internal audits Meet 2x per year with your organization's key decision makers to discuss risks to security and PHI Take and keep minutes of these meetings
Personnel Designations	Personnel	Personnel Designations	Maintain a list of BAs Note: Accountable supports listing your BAsIf your organization is a Covered Entity (CE).... All patients should sign an Notice of Privacy Practices (NPP)
Privacy Policy	Personnel	Privacy	n/a
Restricted Internal Access to PHI	Personnel	Restricted PHI Access	n/a
Sanctions Non Compliance	Personnel	Non Compliance Sanctions	n/a
Security Incident Response	Security Incident	Security Incident Response	Develop your organization's Security Incident Response Plan
Termination Procedures	Personnel	Termination Procedures	Update team member Offboarding Checklists
The Minimum Necessary Requirement	Personnel	Minimum Necessary Requirement	n/a
Transmission Security	Technical Safeguards	Transmission Security	n/a
Viruses and Malware; Application Updates	Technical Safeguards	Malware Policy	Ensure Device Operating System (OS) updates happen in a timely manner Potentially, implement an Anti-Malware Application
Workstation Security	Physical Safeguards	Workstation Security	Setup device Time-Out/Lock Settings to lock after 20 minutes