Incident Response Policy (RES-POL-001)

1. Objective

The objective of this policy is to establish a comprehensive incident response framework for [Company Name] to effectively detect, respond to, contain, and recover from information security incidents. This policy ensures that security incidents are handled in a coordinated, timely, and effective manner to minimize impact on business operations, protect electronic Protected Health Information (ePHI) and other sensitive data, maintain regulatory compliance with HIPAA, HITECH, and SOC 2 mandates, and preserve evidence for potential legal proceedings.

2. Scope

This policy applies to all [Company Name] workforce members, contractors, third parties, and business associates who may detect, report, or respond to information security incidents. It encompasses all information systems, applications, networks, devices, and data owned, operated, or managed by [Company Name], including cloud services, mobile devices, and third-party systems. This policy covers all types of security incidents including but not limited to data breaches, malware infections, unauthorized access, denial of service attacks, and physical security breaches.

3. Policy

[Company Name] shall maintain a formal incident response capability that enables rapid detection, assessment, containment, eradication, and recovery from security incidents while ensuring compliance with regulatory notification mandates.

3.1 Incident Response Framework

[Company Name] shall implement a structured incident response process based on industry best practices and regulatory mandates.

3.1.1 Incident Response Lifecycle

The incident response process shall follow a systematic lifecycle approach based on the NIST Cybersecurity Framework (Prepare, Detect & Analyze, Contain/Eradicate/Recover, Post-Incident Activity).

1. Preparation:

  • Development and at least annual review of the Incident Response Plan (IRP).
  • Establishment and maintenance of a designated Incident Response Team (IRT) with clearly defined roles and responsibilities.
  • Annual training and simulation exercises (e.g., tabletop exercises) for the IRT to ensure readiness, with outcomes documented for improvement tracking.
  • Deployment and maintenance of tools and technologies mandated for incident detection, analysis, and response.
  • Maintenance of secure, out-of-band communication channels for the IRT.
  • At least annual testing of incident response capabilities, with results documented and used to drive improvements.

2. Detection and Analysis:

  • Continuous monitoring of information systems to detect security events.
  • Initial triage of detected events to determine if a potential incident has occurred.
  • Formal declaration of an incident and activation of the Incident Response Team (IRT).
  • Initial impact and severity assessment to classify the incident according to the criteria in section 3.1.2.
  • Establishment of a secure repository for evidence collection and chain of custody documentation.
  • Prioritization of response activities based on the incident classification.

3. Containment, Eradication, and Recovery:

  • Execution of containment strategies to prevent the incident from spreading and to minimize further damage.
  • Identification of the root cause and all affected systems.
  • Eradication of the threat (e.g., removing malware, disabling breached accounts, patching vulnerabilities).
  • Systematic recovery of affected systems and data from trusted sources.
  • Validation that systems are clean and secure before returning them to production.
  • Enhanced monitoring of recovered systems to ensure the threat has been fully removed.

4. Post-Incident Activity:

  • Incident documentation and reporting
  • Lessons learned analysis and improvement recommendations
  • Incident response plan updates
  • Stakeholder communication and follow-up
  • Legal and regulatory compliance activities

3.1.2 Incident Classification

All incidents shall be classified based on their severity and potential impact:

Critical (P1) - Emergency Response Required:

  • Confirmed data breach involving ePHI or large volumes of sensitive data
  • Active compromise of critical systems affecting business operations
  • Widespread malware infection or ransomware attack
  • Suspected nation-state or advanced persistent threat (APT) activity
  • Physical security breach affecting critical assets
  • Response Time: Immediate (within 15 minutes)

High (P2) - Urgent Response Required:

  • Unauthorized access to sensitive systems or data
  • Malware infection on critical systems
  • Denial of service attacks affecting business operations
  • Suspected insider threat activity
  • Social engineering attacks targeting executives or privileged users
  • Response Time: Within 1 hour

Medium (P3) - Standard Response Required:

  • Unsuccessful attack attempts against critical systems
  • Malware infection on non-critical systems
  • Policy violations with potential security impact
  • Suspicious network activity or anomalous behavior
  • Physical security violations in non-critical areas
  • Response Time: Within 4 hours

Low (P4) - Routine Response Required:

  • Security policy violations without immediate risk
  • Failed login attempts within normal thresholds
  • Spam or phishing emails reported by users
  • Minor physical security issues
  • Security awareness training opportunities
  • Response Time: Within 24 hours

3.2 Incident Response Team

A designated Incident Response Team (IRT) shall be established with clearly defined roles and responsibilities.

3.2.1 Core Team Members

Incident Commander:

  • Overall incident response coordination and decision-making authority
  • Communication with executive leadership and external stakeholders
  • Resource allocation and escalation decisions
  • Post-incident review and improvement oversight

Security Analyst:

  • Technical investigation and analysis
  • Evidence collection and preservation
  • Malware analysis and threat intelligence gathering
  • System forensics and artifact examination

System Administrator:

  • System containment and isolation procedures
  • System restoration and recovery activities
  • Network security controls implementation
  • Infrastructure monitoring and maintenance

Privacy Officer:

  • HIPAA breach assessment and notification requirements
  • Regulatory compliance coordination
  • Patient notification and communication
  • Risk assessment for privacy violations

Legal Counsel:

  • Legal implications assessment and guidance
  • Law enforcement coordination and communication
  • Litigation hold and evidence preservation requirements
  • Regulatory notification and compliance support

Communications Lead:

  • Internal and external communication coordination
  • Media relations and public communications
  • Customer and stakeholder notification
  • Crisis communication management

3.2.2 Extended Team Members

Additional team members may be activated based on incident type and severity:

  • Human Resources representative for insider threat incidents
  • Facilities manager for physical security incidents
  • Third-party forensics and investigation specialists
  • Public relations and crisis communication experts
  • External legal counsel and regulatory specialists
  • Business unit leaders and system owners

3.3 Incident Detection and Reporting

Multiple detection methods shall be employed to identify potential security incidents as early as possible.

3.3.1 Detection Methods

Automated Detection:

  • Security Information and Event Management (SIEM) system alerts
  • Intrusion Detection System (IDS) and Intrusion Prevention System (IPS) alerts
  • Antivirus and anti-malware system notifications
  • Data Loss Prevention (DLP) system alerts
  • Network anomaly detection and behavioral analysis
  • File integrity monitoring and system change detection

Manual Detection:

  • Workforce member reports of suspicious activity
  • System administrator observation of anomalous behavior
  • Security team proactive monitoring and hunting activities
  • Third-party security service provider notifications
  • Customer or partner reports of potential compromise
  • Physical security observations and reports

3.3.2 Incident Reporting Procedures

Immediate Reporting Channels:

  • 24/7 security hotline: [Phone Number]
  • Email reporting: [Email Address]
  • Online incident reporting portal: [URL]
  • In-person reporting to Security Officer or designee

Reporting Requirements:

  • All suspected incidents shall be reported within [Timeframe, e.g., 2 hours] of discovery
  • Initial reports may be verbal with written follow-up mandated within [Timeframe, e.g., 24 hours]
  • Reports shall include all available information about the incident
  • Workforce members shall not attempt to investigate incidents independently
  • No retaliation for good faith incident reporting

3.4 Incident Response Procedures

Standardized procedures shall be followed for responding to different types of security incidents.

3.4.1 Initial Response Procedures

Incident Verification:

  • Confirm that a security incident has actually occurred
  • Gather initial information about the scope and impact
  • Classify the incident according to established criteria
  • Activate appropriate incident response procedures
  • Notify relevant incident response team members

Evidence Preservation:

  • Preserve all relevant evidence in its original state
  • Document all actions taken and decisions made
  • Maintain chain of custody for digital and physical evidence
  • Take system snapshots or images before making changes
  • Collect network traffic captures and log files

3.4.2 Containment Procedures

Short-term Containment:

  • Isolate affected systems from the network
  • Disable compromised user accounts and change passwords
  • Block malicious IP addresses and domains
  • Implement temporary firewall rules to prevent spread
  • Preserve system state for forensic analysis

Long-term Containment:

  • Rebuild compromised systems from clean backups
  • Implement enhanced monitoring on affected systems
  • Apply security patches and configuration hardening
  • Conduct security validation before system restoration
  • Monitor for signs of persistent compromise

3.4.3 Eradication and Recovery Procedures

Threat Eradication:

  • Remove malware and malicious artifacts from systems
  • Close security vulnerabilities that enabled the incident
  • Improve security controls to prevent recurrence
  • Validate that all traces of compromise have been eliminated
  • Conduct security assessment of remediated systems

System Recovery:

  • Restore systems and data from clean backups
  • Implement additional security monitoring and controls
  • Gradually restore full system functionality
  • Conduct user acceptance testing and validation
  • Monitor systems for signs of compromise or instability

3.5 Regulatory and Legal Compliance

Incident response procedures shall ensure compliance with all applicable legal and regulatory mandates.

3.5.1 HIPAA Breach Notification Requirements

Breach Assessment:

  • Determine whether incident constitutes a HIPAA breach
  • Assess the probability that ePHI has been compromised
  • Evaluate risk of harm to affected individuals
  • Document the breach assessment decision and rationale

Notification Timelines:

  • HHS notification within 60 days of breach discovery
  • Individual notification within 60 days of breach discovery
  • Media notification if breach affects 500 or more individuals in a state/jurisdiction
  • Immediate notification to HHS if breach affects 500 or more individuals nationwide

3.5.2 Other Regulatory Requirements

State Data Breach Notification Laws:

  • Comply with applicable state notification requirements
  • Determine residency of affected individuals for notification purposes
  • Meet varying state timelines and notification methods
  • Coordinate with state attorneys general as required

Federal and Industry Requirements:

  • SEC notification for material cybersecurity incidents (public companies)
  • Financial industry notifications (if applicable)
  • Professional licensing board notifications (if applicable)
  • Insurance carrier notification and claim procedures

3.6 Communication and Coordination

Effective communication shall be maintained throughout the incident response process.

3.6.1 Internal Communications

Executive Reporting:

  • Immediate notification to CEO/Executive Leadership for Critical incidents
  • Regular status updates throughout incident response
  • Final incident report with lessons learned and recommendations
  • Board of Directors notification for significant incidents

Workforce Communications:

  • Need-to-know basis for incident details
  • General security awareness messages as appropriate
  • Post-incident training and awareness updates
  • Recognition for effective incident reporting and response

3.6.2 External Communications

Customer Communications:

  • Timely notification of customers potentially affected by incidents
  • Clear explanation of incident impact and remediation efforts
  • Regular updates on investigation and recovery progress
  • Contact information for customer questions and concerns

Vendor and Partner Communications:

  • Notification of business associates and vendors as required
  • Coordination with third-party service providers for response activities
  • Information sharing with industry partners and threat intelligence communities
  • Coordination with insurance carriers and coverage providers

3.7 Post-Incident Activities

Comprehensive post-incident activities shall ensure organizational learning and improvement.

3.7.1 Incident Documentation

Incident Report Contents:

  • Complete timeline of incident detection, response, and recovery
  • Root cause analysis and contributing factors
  • Impact assessment including affected systems and data
  • Response effectiveness evaluation and lessons learned
  • Recommendations for security improvements and process enhancements

3.7.2 Lessons Learned and Improvement

Post-Incident Review:

  • Formal review meeting within [Timeframe, e.g., 2 weeks] of incident closure
  • Analysis of response effectiveness and areas for improvement
  • Review of incident response plan adequacy and updates needed
  • Evaluation of team performance and training requirements
  • Assessment of detection capabilities and monitoring effectiveness

Process Improvement:

  • Update incident response procedures based on lessons learned
  • Implement additional security controls to prevent similar incidents
  • Enhance monitoring and detection capabilities
  • Improve training and awareness programs
  • Update business continuity and disaster recovery plans

4. Standards Compliance

This policy is designed to comply with and support the following industry standards and regulations.

Policy Section Standard/Framework Control Reference
All HIPAA Security Rule 45 CFR § 164.308(a)(6) - Security Incident Procedures
3.5.1 HIPAA Breach Notification Rule 45 CFR § 164.400-414 - Notification Requirements
3.3, 3.4 HIPAA Security Rule 45 CFR § 164.312(b) - Audit Controls
All SOC 2 Trust Services Criteria CC7.1 - System Monitoring
3.4, 3.6 SOC 2 Trust Services Criteria CC7.2 - Controls Monitor Effectiveness
3.7 SOC 2 Trust Services Criteria CC2.1 - Communication and Information
All NIST Cybersecurity Framework RS.RP - Response Planning
3.4 NIST Cybersecurity Framework RS.CO - Communications
3.7 NIST Cybersecurity Framework RC.IM - Improvements

5. Definitions

Business Associate: A person or entity that performs functions or activities on behalf of a covered entity involving access to ePHI.

Chain of Custody: Documentation of the chronological transfer of evidence from collection to presentation.

Incident Commander: Individual with overall authority and responsibility for incident response coordination.

Incident Response Team (IRT): Designated group of individuals responsible for detecting, responding to, and recovering from security incidents.

Indicators of Compromise (IOCs): Artifacts observed on networks or operating systems that indicate computer intrusion.

Mean Time to Detection (MTTD): Average time between when an incident occurs and when it is detected.

Mean Time to Recovery (MTTR): Average time to restore normal operations after an incident.

Security Incident: Any event that could result in unauthorized access to, disclosure, modification, or destruction of information assets.

6. Responsibilities

Role Responsibility
Security Officer Develop incident response policies, maintain incident response team, oversee incident investigations, and ensure regulatory compliance.
Incident Commander Lead incident response activities, coordinate team efforts, communicate with stakeholders, and make critical response decisions.
Privacy Officer Assess HIPAA breach requirements, coordinate breach notifications, manage patient communications, and ensure privacy compliance.
IT Security Team Detect and analyze security incidents, perform technical investigations, implement containment measures, and conduct system recovery.
Legal Counsel Provide legal guidance, coordinate law enforcement relations, manage litigation holds, and ensure regulatory compliance.
Communications Team Manage internal and external communications, coordinate media relations, and support crisis communications.
System Administrators Implement technical containment measures, perform system restoration, maintain evidence integrity, and support forensic activities.
Human Resources Support insider threat investigations, manage workforce communications, coordinate with legal team, and handle personnel actions.
All Workforce Members Report suspected incidents promptly, cooperate with investigations, follow incident response procedures, and participate in post-incident training.