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HHS Information Security Program Rated Not Effective for FY24

A review of the U.S. Department of Health and Human Services (HHS) to assess compliance with the Federal Information Security Modernization Act of 2014 (FISMA) for Financial Year 2024 has revealed the HHS information security program is not effective, as was the case with last year’s HHS Office of Inspector General (HHS-OIG) review.

The review assessed maturity levels across the five functions of the Cybersecurity Framework – Identify, Protect, Detect, Respond, and Recover, with the level of maturity given one of 5 scores: Level 1 (Ad hoc); Level 2 (Defined); level 3 (Consistently Implemented); level 4 (Managed and Measurable); and Level 5 (Optimized).

To receive an effective rating, the HHS must achieve a level 4 rating of Managed and Measurable across all five of the functions of the Cybersecurity Framework. The HHS was assessed on core metrics and supplemental metrics across 10 IG FISMA Domains, but only achieved the Managed and Measurable level in two of those Domains – Risk Management and Information Security Continuous Monitoring, with an overall maturity rating for the core and supplemental metrics of Consistently Implemented, hence the determination of a rating of Not Effective across all of the IG FISMA domains.

HHS-OIG made six recommendations to the HHS to strengthen its enterprise-wide cybersecurity program, including the recommendation to focus on the Identify, Protect, and Respond functions.

HHS OIG Exclusions List
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The six recommendations were:

  • Update its enterprise architecture system inventory and software/hardware asset inventories to include the information systems and components that are active on the HHS network.
  • Complete implementation of a cybersecurity risk management strategy to assess and respond to identified risks; watch for new risks; monitor risks and confirm implementation.
  • Require OpDivs to incorporate analyses of security impacts of significant changes prior to implementation to measure its impacts on the organizations’ security and enterprise architecture and confirm implementation.
  • Require OpDivs to implement an effective SCRM program that meets the defined standards across HHS and confirm implementation is consistent with established standards.
  • Require OpDivs to establish oversight of background investigations performed for employees and contractors with logical access across the agency and perform continuous monitoring for new and existing users
  • Confirm that OpDivs’ policies require monitoring of privileged user accounts for both logging and activity reviews, in an automated manner.

The HHS concurred with all but one of the recommendations – The complete implementation of a cybersecurity risk management strategy. The HHS did not concur because OpDiv Chief Information Officers (CIOs) are responsible for implementing their own cybersecurity risk management strategies.

Author: Steve Alder is the editor-in-chief of The HIPAA Journal. Steve is responsible for editorial policy regarding the topics covered in The HIPAA Journal. He is a specialist on healthcare industry legal and regulatory affairs, and has 10 years of experience writing about HIPAA and other related legal topics. Steve has developed a deep understanding of regulatory issues surrounding the use of information technology in the healthcare industry and has written hundreds of articles on HIPAA-related topics. Steve shapes the editorial policy of The HIPAA Journal, ensuring its comprehensive coverage of critical topics. Steve Alder is considered an authority in the healthcare industry on HIPAA. The HIPAA Journal has evolved into the leading independent authority on HIPAA under Steve’s editorial leadership. Steve manages a team of writers and is responsible for the factual and legal accuracy of all content published on The HIPAA Journal. Steve holds a Bachelor’s of Science degree from the University of Liverpool. You can connect with Steve via LinkedIn or email via stevealder(at)hipaajournal.com

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