Policy Management Policy

Fox and Geese implements policies and procedures to maintain compliance and integrity of data. The Security Officer and Privacy Officer are responsible for maintaining policies and procedures and assuring all Fox and Geese workforce members, business associates, customers, and partners are adherent to all applicable policies. Previous versions of policies are retained to assure ease of finding policies at specific historic dates in time.

Applicable Standards

Applicable Standards from the HITRUST Common Security Framework

• 12.c - Developing and Implementing Continuity Plans Including Information Security

Applicable Standards from the HIPAA Security Rule

• 164.316(a) - Policies and Procedures
• 164.316(b)(1)(i) - Documentation

Maintenance of Policies

1. All policies are stored and updated to maintain Fox and Geese compliance with HIPAA, HITRUST, NIST, and other relevant standards. Updates and version control are done similarly to source code control.

2. Policy update requests can be made by any workforce member at any time. Furthermore, all policies are reviewed annually by both the Security and Privacy Officer to assure they are accurate and up-to-date.

3. Fox and Geese employees may request changes to policies using the following process:

   1. The Fox and Geese employee initiates a policy change request by creating an Issue in the Fox and Geese Quality Management System. The change request may optionally include a GitHub pull request from a separate branch or repository containing the desired changes.

   2. The Security Officer or the Privacy Officer is assigned to review the policy change request.

   3. Once the review is completed, the Security Officer or Privacy Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.

   4. If the review is approved, the Security Officer or Privacy Officer then marks the Issue as Done, adding any pertinent notes required.

   5. If the policy change requires technical modifications to production systems, those changes are carried out by authorized personnel using Fox and Geese's Configuration Management Policy.

   6. All policies are made accessible to all Fox and Geese workforce members. The current master policies are published at https://github.com/foxandgeese/policies.

      • Changes are automatically communicated to all Fox and Geese team members through integrations between GitHub and Slack that log all GitHub policy channels to a dedicated Fox and Geese Slack Channel.
      • The Security Officer also communicates policy changes to all employees via email. These emails include a high-level description of the policy change using terminology appropriate for the target audience.

   7. All policies, and associated documentation, are retained for 6 years from the date of its creation or the date when it last was in effect, whichever is later

      1. Version history of all Fox and Geese policies is done via GitHub.
      2. Backup storage of all policies is done with Box.

   8. The policies and information security policies are reviewed and audited annually, or after significant changes occur to Fox and Geese's organizational environment. Issues that come up as part of this process are reviewed by Fox and Geese management to assure all risks and potential gaps are mitigated and/or fully addressed. The process for reviewing polices is outlined below:

   9. The Security Officer initiates the policy review by creating an Issue in the Fox and Geese Quality Management System.

   10. The Security Officer or the Privacy Officer is assigned to review the current Fox and Geese policies (https://github.com/foxandgeese/policies).

   11. If changes are made, the above process is used. All changes are documented in the Issue.

   12. Once the review is completed, the Security Officer or Privacy Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.

   13. If the review is approved, the Security Officer or Privacy Officer then marks the Issue as Done, adding any pertinent notes required.

   14. Policy review is monitored on a quarterly basis using the Quality Management System reporting to assess compliance with above policy.

   15. The Security Officer initiates audit activity by creating an Issue in the Fox and Geese Quality Management System.

   16. The Security Officer or the Privacy Officer is assigned to own and manage the audit activity.

   17. Once the audit activity is completed, the Security Officer approves or rejects the Issue.

   18. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.

   19. Compliance with annual internal compliance assessments—utilizing the HITRUST CSF as an informal guide—is monitored on a quarterly basis using the Quality Management System reporting to assess compliance with above policy.

Additional documentation related to maintenance of policies is outlined in Roles Policy.