IAPP CIPP-US Practice Test - Questions Answers, Page 7

Phishing is a form of social engineering that involves sending fraudulent emails or other messages that appear to come from a legitimate source, but are designed to trick recipients into revealing sensitive information, such as passwords, account numbers, or personal identifiers1.Phishing is one of the most common and effective methods of cyberattacks, and it can lead to data breaches, identity theft, ransomware infections, or other serious consequences2.Therefore, training on how to recognize and avoid phishing attempts is crucial for any organization that handles sensitive data, especially ePHI, which is subject to strict regulations under HIPAA3. Training on techniques for identifying phishing attempts can help employees to spot the signs of a phishing email, such as:

Sender's address or domain name that does not match the expected source or contains spelling errors4

Generic salutations or impersonal tone that do not address the recipient by name or use proper grammar4

Urgent or threatening language that creates a sense of pressure or fear and asks the recipient to take immediate action, such as clicking on a link, opening an attachment, or providing information4

Suspicious links or attachments that may contain malware or lead to fake websites that mimic the appearance of a legitimate site, but have a different URL or request login credentials or other data4

Requests for sensitive information that are unusual or out of context, such as asking for passwords, account numbers, or personal identifiers that the sender should already have or should not need4

Training on techniques for identifying phishing attempts can also help employees to learn how to respond to a phishing email, such as:

Not clicking on any links or opening any attachments in the email4

Not replying to the email or providing any information to the sender4

Reporting the email to the IT department or security team and deleting it from the inbox4

Verifying the legitimacy of the email by contacting the sender directly using a different channel, such as phone or another email address4

Updating the antivirus software and scanning the device for any malware infection4

Training on techniques for identifying phishing attempts is the most effective kind of training that CloudHealth could have given its employees to help prevent this type of data breach, because it would have enabled them to recognize the phishing email that compromised the PHI of more than 10,000 HealthCo patients, and to avoid falling victim to it. Training on the terms of the contractual agreement with HealthCo, the difference between confidential and non-public information, or CloudHealth's HR policy regarding the role of employees involved in data breaches, while important, would not have been as effective in preventing this specific type of data breach, because they would not have addressed the root cause of the breach, which was the phishing email.

1: IAPP, Phishing, https://iapp.org/resources/glossary/phishing/

2: SpinOne, The Top 5 Phishing Awareness Training Providers 2023, https://spinbackup.com/blog/phishing-awareness-training-best-providers/

3: IAPP, HIPAA, https://iapp.org/resources/glossary/hipaa/

4: Expert Insights, The Top 11 Phishing Awareness Training and Simulation Solutions, https://expertinsights.com/insights/the-top-11-phishing-awareness-training-and-simulation-solutions/

The HIPAA Security Rule requires covered entities and their business associates to implement three types of safeguards to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI): administrative, physical, and technical1. Security safeguards is not a separate category of safeguards, but rather a general term that encompasses all three types. Therefore, it is not a correct answer to the question.

Administrative safeguards are the policies and procedures that govern the conduct of the workforce and the security measures put in place to protect ePHI.They include risk analysis and management, training, contingency planning, incident response, and evaluation12.

Physical safeguards are the locks, doors, cameras, and other physical measures that prevent unauthorized access to ePHI.They include workstation and device security, locks and keys, and disposal of media12.

Technical safeguards are the software and hardware tools that protect ePHI from unauthorized access, alteration, or destruction.They include access control, encryption, audit controls, integrity controls, and transmission security12.

In the scenario, HealthCo's actions have potentially violated all three types of safeguards. For example:

HealthCo did not perform due diligence on CloudHealth before entering the contract, and has not conducted audits of CloudHealth's security measures.This could be a breach of the administrative safeguard of risk analysis and management12.

HealthCo discovers that CloudHealth has not encrypted the PHI in accordance with the terms of its contract.This could be a breach of the technical safeguard of encryption12.

HealthCo provides its investigative report of the breach and a copy of the PHI of the individuals affected to law enforcement.This could be a breach of the physical safeguard of disposal of media, if HealthCo did not ensure that the media was properly erased or destroyed after the transfer12.

The HIPAA privacy rule establishes national standards to protect individuals' medical records and other individually identifiable health information (collectively defined as ''protected health information'') and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically (collectively defined as ''covered entities'')1The rule requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without an individual's authorization1The rule also gives individuals rights over their protected health information, including rights to examine and obtain a copy of their health records, to direct a covered entity to transmit to a third party an electronic copy of their protected health information in an electronic health record, and to request corrections1

The HIPAA privacy rule permits a covered entity to disclose protected health information for the litigation in response to a court order, subpoena, discovery request, or other lawful process, provided the applicable requirements of 45 CFR 164.512 (e) for disclosures for judicial and administrative proceedings are met2These requirements include:

In response to a court order or administrative tribunal order, the covered entity may disclose only the protected health information expressly authorized by such order2

In response to a subpoena, discovery request, or other lawful process that is not accompanied by a court order or administrative tribunal order, the covered entity must receive satisfactory assurances that the party seeking the information has made reasonable efforts to ensure that the individual who is the subject of the information has been given notice of the request, or that the party seeking the information has made reasonable efforts to secure a qualified protective order2

A qualified protective order is an order of a court or administrative tribunal or a stipulation by the parties to the litigation or administrative proceeding that prohibits the parties from using or disclosing the protected health information for any purpose other than the litigation or proceeding for which such information was requested and requires the return to the covered entity or destruction of the protected health information (including all copies made) at the end of the litigation or proceeding2

Option A is incorrect because the HIPAA privacy rule does not only permit disclosure for payment, treatment or healthcare operations.The rule also allows disclosure for other purposes, such as public health, research, law enforcement, judicial and administrative proceedings, as long as the applicable conditions and limitations are met1

Option B is correct because it is consistent with the HIPAA privacy rule's requirement for disclosures for judicial and administrative proceedings.By responding with a request for satisfactory assurances such as a qualified protective order, HealthCo is ensuring that the protected health information will be used only for the litigation and will be returned or destroyed afterwards2

Option C is incorrect because it is not consistent with the HIPAA privacy rule's requirement for disclosures for judicial and administrative proceedings.By turning over all of the compromised patient records to the plaintiff's attorney, HealthCo is disclosing more information than necessary and may violate the privacy rights of other individuals who are not parties to the lawsuit2

Option D is incorrect because it is not consistent with the HIPAA privacy rule's requirement for disclosures for judicial and administrative proceedings.By responding with a redacted document only relative to the plaintiff, HealthCo is not providing satisfactory assurances that the protected health information will be used only for the litigation and will be returned or destroyed afterwards2

The HIPAA Privacy Rule generally prohibits covered entities and business associates from disclosing protected health information (PHI) to law enforcement without the individual's authorization, unless one of the exceptions in 45 CFR 164.512 applies. These exceptions include disclosures required by law, disclosures for law enforcement purposes, disclosures about victims of abuse, neglect or domestic violence, disclosures for health oversight activities, disclosures for judicial and administrative proceedings, disclosures for research purposes, disclosures to avert a serious threat to health or safety, disclosures for specialized government functions, disclosures for workers' compensation, and disclosures to coroners and medical examiners. None of these exceptions apply to the type of information in option D, which is personal health information that is not related to any of the above purposes. Therefore, an organization would generally not be required to disclose such information to law enforcement under the HIPAA Privacy Rule.Reference:https://www.justice.gov/opcl/overview-privacy-act-1974-2020-edition/disclosures-third-parties

https://bing.com/search?q=information+disclosure+to+law+enforcement

https://hipaatrek.com/law-enforcement-hipaa-disclosing-phi/

The law that ACME violated by designing the service to prevent access to the information by a law enforcement agency is theCommunications Assistance for Law Enforcement Act (CALEA)1.CALEA is a federal law that requires telecommunications carriers and manufacturers of telecommunications equipment to design their equipment, facilities, and services to ensure that they have the necessary surveillance capabilities to comply with legal requests for interception of communications2.CALEA applies to all commercial messages, including text messages, and gives law enforcement agencies the authority to subpoena the records of such communications from the service providers3.By encrypting its text message records so that only the suspect could access this data, ACME violated CALEA's duty to cooperate in the interception of communications for law enforcement purposes.Reference:1:Communications Assistance for Law Enforcement Act - Wikipedia2:Home | CALEA | The Commission on Accreditation for Law Enforcement Agencies, Inc.3:Communications Assistance for Law Enforcement Act: IAPP CIPP/US Certified Information Privacy Professional Study Guide, Chapter 6: Law Enforcement and National Security Access, p. 177

Redaction is the permanent removal of sensitive data---the digital equivalent of ''blacking out'' text in printed material. Redaction can be accomplished by simply deleting characters from a file or database record, or by replacing characters with asterisks or other placeholders. Redaction is often used to protect personal information, such as names, addresses, social security numbers, or financial data, on documents that are disclosed in litigation, such as pleadings, exhibits, or discovery responses. Redaction is required by courts to comply with privacy laws and rules, such as the Federal Rules of Civil Procedure (FRCP), which mandate that parties must redact certain types of personal information from documents filed with the court or produced to the other party. Redaction is also a best practice to minimize the risk of unauthorized access, identity theft, or reputational harm that may result from exposing personal information in litigation.Reference:

When to redact, or not, disclosable documents in litigation - Stewarts

The approach to redaction -- High Court guidance - Lexology

IAPP CIPP/US Certified Information Privacy Professional Study Guide, Chapter 3: Federal Privacy Laws and Regulations, Section 3.2: Federal Rules of Civil Procedure (FRCP).

The Electronic Communications Privacy Act of 1986 (ECPA) is a federal law that regulates the privacy of wire, oral, and electronic communications.The ECPA prohibits the intentional interception, use, or disclosure of such communications, unless authorized by law or by the consent of one of the parties to the communication12.The ECPA also provides exceptions for certain types of communications, such as those made in the normal course of business, those made for law enforcement purposes, or those made for foreign intelligence purposes12.

One of the exceptions to the ECPA ban on interception is where one of the parties has given consent. This means that if a person who is a party to a communication agrees to have it intercepted, the interception is lawful under the ECPA.Consent can be express or implied, depending on the circumstances and the expectations of the parties3. For example, if a person calls a customer service line and hears a recorded message that the call may be monitored or recorded, the person has impliedly consented to the interception of the call. However, if a person calls a friend and does not know that the friend has a third party listening in on the call, the person has not consented to the interception of the call.

The Foreign Intelligence Surveillance Act (FISA) was enacted in 1978 in response to revelations of widespread privacy violations by the federal government under President Nixon.It established procedures for requesting judicial authorization for electronic surveillance and physical search of persons engaged in espionage or international terrorism against the United States on behalf of a foreign power1The original purpose of FISA was to further define a framework for authorizing wiretaps by the executive branch for national security purposes under Article II of the Constitution, which grants the president the power to conduct foreign affairs and defend the nation23FISA was intended to balance the need for collecting foreign intelligence information with the protection of privacy and civil liberties of U.S.persons4Reference: https://www.intelligence.gov/foreign-intelligence-surveillance-act

https://www.intelligence.gov/foreign-intelligence-surveillance-act/1234-categories-of-fisa

The USA FREEDOM Act is a law that was enacted in 2015 to reform the surveillance practices of the U.S. government. The law was a response to the revelations by Edward Snowden about the mass collection of phone records and internet data by the National Security Agency (NSA) under the authority of Section 215 of the USA PATRIOT Act. The USA FREEDOM Act ended the bulk collection of telephone data and internet metadata by the NSA, and instead required the government to obtain a specific order from the Foreign Intelligence Surveillance Court (FISC) to access such data from the telecommunication providers. The law also authorized the following practices:

Emergency exceptions that allow the government to target roamers: The law allows the government to temporarily target a non-U.S. person who is using a phone number or identifier of a U.S. person, without a court order, if there is an emergency situation that involves a threat of death or serious bodily harm. The government must obtain a court order within seven days to continue the surveillance.

An increase in the maximum penalty for material support to terrorism: The law increases the maximum prison term for providing material support or resources to a foreign terrorist organization from 15 years to 20 years.

An extension of the expiration for roving wiretaps: The law extends the sunset date for the roving wiretap provision of the USA PATRIOT Act, which allows the government to obtain a single order from the FISC to conduct surveillance on a target who switches devices or locations, without specifying the device or location. The law extends the expiration date from June 1, 2015 to December 15, 2019.Reference:

USA FREEDOM Act

USA FREEDOM Act Summary

USA FREEDOM Act FAQs