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CMMC: Is it time for your cybersecurity program to grow up?

09.29.23 /

Read this if you are involved in cybersecurity at your organization.

The cyber threat landscape is growing

Over the years, the cyber threat landscape has experienced a steady increase in cyberattacks, with more data breaches, targeted social engineering attacks, and crippling ransomware attacks taking place. The increase in cyberattacks is affecting all industries, including government supply chain vendors, higher education and research institutions, and many others. 

The US government is particularly aware of the risks involved with the increase in cyberattacks and understands it must continue to strengthen its cybersecurity program to protect intellectual property and national security. This means not only strengthening cybersecurity controls and processes for the government, but also for contractors who work directly and indirectly with the government. In this case, “contractors” include businesses that enter into contracts with the US government and any supplier, distributor, vendor, or firm that provides products or services to contractors and other subcontractors. 

What is the Cybersecurity Maturity Model Certification (CMMC) framework?

The CMMC framework provides a foundation for establishing a strong cybersecurity program to effectively manage cyber threats. The framework was developed by the Department of Defense (DoD) and is designed to help ensure that cybersecurity controls and processes adequately protect sensitive information that is shared among entities across various industries. Broadly speaking, contractors and subcontractors that work with the DoD will be required to comply with CMMC guidelines. 

Prior to the enforcement of CMMC, contractors were responsible for implementing and monitoring their own cybersecurity controls and processes and could self-attest to their level of security. In other words, the DoD did not audit or verify the level of security maintained by contractors. But now with cyber criminals frequently targeting the weakest link in supply chains, the DoD has responded by moving to a trust-but-verify approach, meaning organizations working with the DoD may be required to have a third party (also called a C3PAO) assess cybersecurity controls and processes and verify CMMC compliance. 

CMMC industry standards and cybersecurity best practices

Although the framework is evolving and requirements are still being finalized, CMMC currently mandates NIST 800-171 compliance and adds additional requirements coming from other cybersecurity frameworks, including the National Institute of Standards and Technology (NIST) Cybersecurity Framework (CSF), Center for Internet Security (CIS) Controls, and the Computer Emergency Response Team (CERT) Resilience Management Model (RMM). CMMC uses these industry standards and cybersecurity best practices to establish a benchmark against which assessors can measure an organization’s cybersecurity posture. Following the assessment, the organization will better understand the maturity of their controls and processes and where gaps may exist. 

CMMC compliance benefits beyond the DoD

CMMC compliance will soon become a prerequisite for DoD contract awards and is expected to impact over 300,000 contractors and subcontractors. The purpose of CMMC is to provide a uniform set of security standards that every contractor working with the DoD must use to protect sensitive information. Without compliance, organizations could be excluded from bidding on DoD contracts. By 2025, every organization doing business with the DoD must be CMMC compliant, including those entities conducting research using federal grant funds. 

Outside of helping companies with DoD contract prerequisites, CMMC compliance is important for several other reasons. First, the framework helps ensure that organizations have implemented the proper controls and processes to protect themselves from cyber threats. It also helps ensure compliance with other laws and regulations. Additionally, by following the CMMC set of standards and best practices, organizations can maintain a high trust relationship with partners and customers. 

Who should be CMMC compliant?

All contractors and subcontractors that work with the DoD should be CMMC certified. The required maturity level will depend on the DoD contract and the sensitivity of information the organization receives or uses. Today, only organizations that directly provide products and services to the DoD, known as prime contractors, must meet NIST 800-171 and additional requirements of CMMC compliance. Prime contractors must also verify that subcontractors further down the supply chain also meet requirements. By 2025, CMMC compliance obligations will extend to all organizations bidding on defense contracts. At that point, all organizations working with the DoD, no matter what service or services they provide, will need at least Level 1 CMMC compliance to win or maintain a DoD contract (more information on maturity levels below). 

If an organization is planning to contract with the DoD, they should plan to be CMMC certified and should preemptively attain Level 1 CMMC compliance. Again, the maturity level required by an organization will be stipulated on a case-by-case basis in the contract. Fortunately, if an organization is already compliant with NIST 800-53 or FedRAMP (the security standard for all government contractors generally), they are not far from becoming certified. Likewise, if an organization is compliant with NIST 800-171, they may already fulfill many of the requirements of CMMC. 

A breakdown of CMMC maturity levels

In September 2020, the DoD established CMMC 1.0. The original framework organized security maturity levels into five tiers, but in November 2021, the DoD announced the most recent version, CMMC 2.0, which introduces several key changes, including a more streamlined model that should reduce costs, particularly for smaller organizations. Additionally, CMMC 2.0 organizes maturity levels into three tiers—instead of five.

  1. Foundational
    The first tier includes basic cybersecurity hygiene appropriate for small organizations utilizing a subset of universally accepted best practices. This tier only requires an annual self-assessment and attestation by company leadership.
  2. Advanced
    The second tier includes coverage of all 110 NIST SP 800-171 controls. This tier will require a CMMC third-party Assessment Organization (C3PAO) to perform a triennial assessment of their CMMC implementation.
  3. Expert
    The final tier includes implementing highly advanced cybersecurity controls and processes. The processes involved at this level include continuous improvement across the organization and timely incident response capabilities. The details of this tier are still being defined, but it is expected that it will incorporate a subset of controls from NIST 800-172. Additionally, the organization would be assessed by the DoD and not by a C3PAO. 

Challenges and considerations of CMMC compliance 

CMMC compliance can be challenging for several reasons. The first challenge refers to the extent of CMMC compliance for the organization, whether you are starting from scratch or modifying another cybersecurity framework. The CMMC’s core is comprised of the 14 cybersecurity domains outlined in NIST 800-171. The domains include areas such as access control, awareness and training, and incident response. Within the 14 domains there are 110 controls. These controls include topics like limiting unsuccessful login attempts, ensuring that personnel are trained to carry out their assigned information security-related duties and responsibilities, and testing organizational incident response capabilities. Mapping all these security requirements is not easy and implementing them without a clear idea of what they entail is almost impossible.

Another common challenge with CMMC compliance is cost, and organizations should begin to build budgets to upgrade cybersecurity controls and processes to the levels needed. The costs associated with CMMC compliance depend on several factors:

  • Organization size
    The size of the organization may have an impact on project costs; however, the number of employees accessing sensitive information is the more significant driver in determining overall costs of compliance. Thus, organizations should limit the number of employees receiving and using sensitive information. 
  • Maturity
    The journey to CMMC compliance will likely cost more and take longer for organizations starting from scratch. For organizations further along in the process, it will be important to consider the current maturity level of documentation development, technology implementation, and what processes and procedures are already documented and in use. 
  • Technology implementation
    Achieving compliance will require a combination of policy and technology. The more technologies the organization must implement, the greater the costs. Some of the more expensive technologies include a security incident and event management (SIEM) system and vulnerability scanner.
  • Consultants
    Consulting costs should be considered when setting out for CMMC compliance. Organizations often have consultants perform a gap analysis to analyze how well their current cybersecurity program meets—or does not meet—the demands of NIST 800-171. This helps an organization determine whether it complies with the CMMC, or what steps will be necessary to achieve compliance. In other words, a gap analysis can keep the organization’s CMMC compliance strategy on track.

It is important that organizations understand that CMMC compliance is not a one-time expense. Compliance can have an impact on IT support teams, forcing units to spend time on regulated data environments at the cost of supporting broader organizational needs. Ongoing training is necessary to keep stakeholders up to date on the evolving threat landscape. Requirements are also not easy to implement and may have an impact on the organization. Finally, noncompliance carries its own risks, such as not qualifying for new awards or the potential loss of current projects. 

The last challenge to completing CMMC compliance is getting the official certification. Contrary to many other frameworks, the organization must obtain the certification from a C3PAO that has been granted accreditation by the CMMC Accreditation Body/The Cyber AB.

Preparing for CMMC compliance

Before achieving CMMC compliance, organizations should understand their current state of security and determine what level of compliance is necessary. Organizations should perform a gap analysis to analyze how their current cybersecurity program meets—or does not meet—compliance requirements. Following the analysis, organizations should develop a security roadmap that outlines how they will implement requirements to prepare for a CMMC assessment. It will also be important for the organization to determine the scope of the assessment. 

For organizations that are ready to attain CMMC compliance, the next step is to perform the assessment. A CMMC assessment is the process of assessing an organization’s cybersecurity maturity, and it is required to demonstrate an organization’s compliance with the desired CMMC level before being certified. For organizations looking to achieve Level 1 CMMC compliance, an assessment can be performed through a self-assessment. Any organizations that intend to attain Level 2 or 3 compliance need to pass a third-party assessment.

CMMC assessments examine the cybersecurity policies, procedures, controls, and processes to determine compliance with NIST 800-171, NIST 800-172, and any other requirements. The extent of the assessment will depend on the maturity level an organization wants to achieve. The assessor will request information to evaluate the controls and processes protecting sensitive information, which may include previous risk assessments, network diagrams, vulnerability scans, and other relevant documentation. 

Conclusion

In today’s rapidly evolving environment, the DoD is focused on protecting sensitive information from malicious cyberattacks, particularly throughout the supply chain. CMMC offers a structured framework for organizations to strengthen their cybersecurity posture. For organizations doing business or looking to do business with the DoD, CMMC compliance will soon be required to help ensure that contractors are meeting minimum industry standards and cybersecurity best practices. 

While the road to compliance presents challenges like resource allocation and technological adaptation, the journey toward compliance is an ongoing process. To help ensure compliance, organizations should establish transparent ownership and consistent expectations across their enterprise and partnerships.

Topics: cybersecurity

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BerryDunn experts and consultants

More and more emphasis is being put on cybersecurity by companies of all sizes. Whether it’s the news headlines of notable IT incidents, greater emphasis on the value of data, or the monetization of certain types of attacks, an increasing amount of energy and money is going towards security. Security has the attention of leadership and the board and it is not going away. One of the biggest risks to and vulnerabilities of any organization’s security continues to be its people. Innovative approaches and new technology can reduce risk but they still don’t prevent the damage that can be inflicted by an employee simply opening an attachment or following a link. This is more likely to happen than you may think.

Technology also doesn’t prepare a management team for how to handle the IT response, communication effort, and workforce management required during and after an event. Technology doesn’t lessen the operational impact that your organization will feel when, not if, you experience an event.

So let’s examine the human and operational side of cybersecurity. Below are three factors you should address to reduce risk and prepare your organization for an event:

  1. People: Create and maintain a vigilant workforce
    Ask yourself, “How prepared is our workforce when it comes to security threats and protecting our data? How likely would it be for one of our team members to click on a link or open an attachment that appear to be from our CFO? Would our team members look closely enough at the email address and notice that the organization name is different by one letter?”
     

    According to the 2016 Verizon Data Breach Report, 30% of phishing messages were opened by the target across all campaigns and 12% went on to click on the attachment or link.

    Phishing email attacks directed at your company through your team range from very obvious to extremely believable. Some attempts are sent widely and are looking for just one person to click, while others are extremely targeted and deliberate. In either case, it is vital that each employee takes enough time to realize that the email request is unusual. Perhaps there are strange typos in the request or it is odd the CFO is emailing while on vacation. That moment your employees take to pause and decide whether to click on the link/attachment could mean the difference between experiencing an event or not.

    So how do you create and cultivate this type of thought process in your workforce? Lots of education and awareness efforts. This goes beyond just an annual in-service training on HIPAA. It may include education sessions, emails with tips and tricks, posters describing the risk, and also exercises to test your workforce against phishing and security exploits. It also takes leadership embracing security as a strategic imperative and leading the organization to take it seriously. Once you have these efforts in place, you can create culture change to build and maintain an environment where an employee is not embarrassed to check with the CFO’s office to see if they really did send an email from Bora Bora.
  1. Plan: Implement a disaster recovery and incident response plan 
    Through the years, disaster recovery plans have been the usual response. Mostly, the emphasis has been on recovering data after a non-security IT event, often discussed in context of a fire, power loss, or hardware failure. Increasingly, cyber-attacks are creeping into the forefront of planning efforts. The challenge with cyber-events is that they are murkier to understand – and harder for leadership – to assist with.

    It’s easier to understand the concept of a fire destroying your server room and the plan entailing acquiring new equipment, recovering data from backup, restoring operations, having good downtime procedures, and communicating the restoration efforts along the way. What is much more challenging is if the event begins with a suspicion by employees, customers, or vendors who believe their data has been stolen without any conclusive information that your company is the originating point of the data loss. How do you take action if you know very little about the situation? What do you communicate if you are not sure what to say? It is this level of uncertainty that makes it so difficult. Do you have a plan in place for how to respond to an incident? Here are some questions to consider:
     
    1. How will we communicate internally with our staff about the incident?
    2. How will we communicate with our clients? Our patients? Our community?
    3. When should we call our insurance company? Our attorney?
    4. Is reception prepared to describe what is going on if someone visits our office?
    5. Do we have the technical expertise to diagnose the issue?
    6. Do we have set protocols in place for when to bring our systems off-line and are our downtime procedures ready to use?
    7. When the press gets wind of the situation, who will communicate with them and what will we share?
    8. If our telephone system and network is taken offline, how we will we communicate with our leadership team and workforce?

By starting to ask these questions, you can ascertain how ready you may, or may not be, for a cyber-attack when it comes.

  1. Practice: Prepare your team with table top exercises  
    Given the complexity and diversity of the threats people are encountering today, no single written plan can account for all of the possible combinations of cyber-attacks. A plan can give guidance, set communication protocols, and structure your approach to your response. But by conducting exercises against hypothetical situations, you can test your plan, identify weaknesses in the plan, and also provide your leadership team with insight and experience – before it counts.

    A table top exercise entails one team member (perhaps from IT or from an outside firm) coming up with a hypothetical situation and a series of facts and clues about the situation that are given to your leadership team over time. Your team then implements the existing plans to respond to the incident and make decisions. There are no right or wrong answers in this scenario. Rather, the goal is to practice the decision-making and response process to determine where improvements are needed.

    Maybe you run an exercise and realize that you have not communicated to your staff that no mention of the event should be shared by employees on social media. Maybe the exercise makes you realize that the network administrator who is on vacation at the time is the only one who knows how to log onto the firewall. You might identify specific gaps that are lacking in your cybersecurity coverage. There is much to learn that can help you prepare for the real thing.

As you know, there are many different threats and risks facing organizations. Some are from inside an organization while others come from outside. Simply throwing additional technology at the problem will not sufficiently address the risks. While your people continue to be one of the biggest threats, they can also be one of your biggest assets, in both preventing issues from occurring and then responding quickly and appropriately when they do. Remember focus on your People, Your Plan, and Your Practice.

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Editor’s note: read this if you work for, or are affiliated with, a charitable organization that receives donations. Even the most mature nonprofit organizations may miss one of these filings once in a while. Some items (e.g., the donor acknowledgment letter) may feel commonplace, but a refresher—especially at a particularly busy time of the year as it pertains to giving—can fend off fines.

As the holiday season is now in full swing, the season of giving is also upon us. Perhaps not surprisingly, the month of December is by far the most charitable month of the year, accounting for almost one-third of all charitable gifts made annually. And with all that giving comes the requirement of charitable organizations to provide donor acknowledgments, a formal “thank you” of the gift being received. Different gifts require differing levels of acknowledgment, and in some cases an additional IRS form (or two) may need to be filed. Doing some work now may save you time (and a fine or two) later. 

While children are currently busy making lists for Santa Claus, in the spirit of giving we present to you our list of donor acknowledgment requirements―and best practices―to help you gain control of this issue for the holiday season and beyond.

Donor acknowledgment letters

Charitable (i.e., 501(c)(3)) organizations are required to provide a donor acknowledgment letter to each donor contributing $250 or more to the organization, whether it be cash or non-cash items (i.e., publicly traded securities, real estate, artwork, vehicles, etc.) received. The letter should include the following: 

  1. Name of the organization
  2. Amount of cash contribution
  3. Description of non-cash items (but not the value) 
  4. Statement that no goods and services were provided (assuming this is the case)
  5. Description and good faith estimate of the value of goods and services provided by the organization in return for the contribution, if any
  6. Statement that goods or services provided by the organization in return for the contribution consisted entirely of intangible religious benefit, if any

It is not necessary to include either the donor’s social security number or tax identification number on the written acknowledgment and as a best practice should not be included in the letter.

In addition to including the elements above, the written acknowledgment is also required to be contemporaneous, that is, sent out in a timely fashion. According to the IRS, a donor must receive the acknowledgment by the earlier of:

  • The date on which the donor actually files his or her individual federal income tax return for the year of the contribution
  • The due date (including extensions) of the return in order to be considered contemporaneous

Quid pro quo disclosure statements

When a donor makes a payment greater than $75 to a charitable organization partly as a contribution and partly as a payment for goods and services, a disclosure statement is required to notify the donor of the value of the goods and services received in order for the donor to determine the charitable contribution component of their payment.

An example of this would be if the organization sold tickets to its annual fundraising dinner event. Assume the ticket costs $100 and at the event the ticketholder receives a dinner valued at $40. In this example, the donor’s tax deduction may not exceed $60. Because the donor’s payment (quid pro quo contribution) exceeds $75, the charitable organization must furnish a disclosure statement to the donor, even though the deductible amount doesn’t exceed $75.

It’s important to note that there are some exclusions to these requirements if the value received is considered to be de minimis (known as the Token Exception), but the value received needs to be relatively small (e.g., receiving a coffee mug with a picture of the organization’s logo on it). Please consult your tax advisor for more details.

If the organization does not issue disclosure statements, the IRS can issue penalties of $10 per contribution, not to exceed $5,000 per fundraising event or mailing. An organization may be able to avoid the penalty if reasonable cause can be demonstrated.

Receiving or selling donated noncash property? Forms 8283 & 8282 may be required.

If a charitable organization receives noncash donations, it may be asked to sign Form 8283. This form is required to be filed by the donor and included with their personal income tax return. If a donor contributes noncash property (excluding publicly traded securities) valued at over $5,000, the organization will need to sign Form 8283, Section B, Part IV acknowledging receipt of the noncash item(s) received.

By signing Form 8283, the donee organization is not only acknowledging receipt, but is also affirming that if the property being received is sold, exchanged, or otherwise disposed of within three years of the original donation date, the organization will be required to file Form 8282. A copy of this form is filed with the IRS and must also be provided to the original donor. Form 8282 is not required for sales of donated publicly traded securities. The penalty for failure to file Form 8282 when required is generally $50 per form.

Cars, boats, and yes, even airplanes? That would be Form 1098-C.

An airplane? Yes, even an airplane can be donated, and the donee organization must file a separate Form 1098-C, Contributions of Motor Vehicles, Boats, and Airplanes, with the IRS for each contribution of a qualified vehicle that has a claimed value of more than $500. Contemporaneous written acknowledgment requirements apply here too, and Form 1098-C can act as acknowledgment for this purpose. An acknowledgment is considered contemporaneous if it is furnished to the donor no later than 30 days after the date of the contribution if you plan to use the item for a mission-related purpose, or 30 days after the date of the sale of the item to an unrelated third party.

Penalties for failure to provide contemporaneous written acknowledgment for qualified vehicles can be pretty stiff, generally calculated as a percentage of the sale price if sold, or a percentage of the claimed value if not sold. Should you have any questions or receive a request regarding any of the forms noted above, please consult your tax advisor.

As you can see, the rules around donor acknowledgments can seem a lot like Grandma’s fruitcake―complex and perhaps a bit on the nutty side. When issuing donor acknowledgments this holiday season and beyond, be sure to review the list above and check it twice. Doing so may end up keeping you off of the IRS’s naughty list!

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Donor acknowledgments: We have to file what?

Editor's note: Read this if you are a CTO, CIO, or administrator at a college or university. This is the first blog in a series on business lessons and best practices from American literature. For this series, interviewees select from a list of American literary quotes through which to view, and discuss, their focus or industry. The goal? To generate some novel insight.

The interviewees: David Houle and Joseph Traino, consultants at BerryDunn
The focus: Higher education
The quote: “Our inventions are wont to be pretty toys . . . They are but improved means to an unimproved end.”  -- Henry David Thoreau, Walden; or, Life in the Woods

Thoreau wrote this shortly after the Industrial Revolution. How does its cynicism apply to higher education during the Digital Revolution?

David Houle (DH): It speaks to my basic philosophy about applying technology to the needs of higher education clients. I’m not a “technology for the sake of technology” cheerleader. 

Joseph Traino (JT): People often believe that applying new technology to a business problem is going to solve the business problem. That rarely happens. For example, most higher education clients have a student information system. These clients often feel that, in order to resolve certain issues, they should update the system software, whereas the issues are often resolved by updating business practices to be more efficient and effective. 

DH: Right. We are often brought in to identify needed technology changes but end up stressing practices, processes, and people. If staff can’t correctly use a new technology, then the technology will not provide a real, valuable service.

When implementing a new technology, what’s the #1 thing that a higher education institution can do to prevent or avoid “an unimproved end”?

JT: Fully understand the technology’s impact on stakeholders, such as students, faculty, and staff, and answer the “why?”

DH: Keep people in mind and gain their buy-in when making technology decisions.

What technology, or technology-related change, is going to have the biggest effect on higher education over the next five years?

DH: Clients love to ask us this question (laughs). And if I truly knew the answer, I’d be on some Caribbean island right now, filthy rich and sipping a piña colada. That said, I think the technology demands of the new workforce are going to have the biggest effect. To paraphrase the new workforce: “I don’t want to stare at a green screen. And what in the world is DOS?” Conversely, the personnel who used to support these homegrown, in-house “green screen” products want to retire and leave the workforce. 

JT: I agree that the demands of the new workforce will continue to affect higher education and steer institutions away from term-based courses and programs and toward more flexible, student-centric courses and programs. From a technology standpoint, I think AI and bots are going to replace many of the manual processes that we still see today in higher education. These new technologies will create greater efficiencies—but also possibly reduce jobs—at institutions.

DH: Higher education leaders with vision have already grasped this idea of cutting administrative costs wherever possible, because those costs are not what place students in seats—or in front of screens. On the flip side, advising is currently an underserved area in higher education. So there is an opportunity for leaders to reallocate administrative resources to fulfill advising roles and to help students—such as at-risk and first-generation students—not just in the classroom, but through their learning journey.

Circling back to the Thoreau quote, I’m sure many higher education staff fear technology will lead to “unimproved ends” for their careers. How do you navigate those fears when working with clients? 

JT: It’s certainly a challenge. We currently face some of those fears when working with IT departments—more services are being moved to the cloud, and there is less of a need for on-site database administrators and system administrators, as an example. Alluding to what Dave said about advising, I think many higher education jobs can be shifted to provide interactive high-tech, high-touch services to students.

DH: And to be blunt, some people don’t want to shift, don’t want to change. The people part is the most challenging part of technology adoption. 

In this discussion about technology, we keep returning to people—and the people side of change. Are higher education clients typically responsive to the concept of change management?

JT: There’s typically some reticence, and a lack of understanding about the value of change management. In most cases, change management requires an investment beyond the technology investment. But change management is key to success. 

DH: Reticence is a good word. Yet I do think that views about change management are changing rapidly. Higher education leaders who have been through a significant system or process change now seem to understand the value of change management and know that change management is a necessity, not a luxury. 

In the end, are you confident that new technology is going to benefit students and their educational goals? 

DH: I’m unsure if technology improves the quality of education. However, I am sure that technology increases the options for the delivery of education. And greater flexibility in education delivery is certainly beneficial, especially because the traditional student is now non-traditional. Ongoing and 24/7 access demands in education are here to stay.

JT: I agree with Dave wholeheartedly. I think technology will help improve the means to the end, but I’m not sure if technology is going to improve the end. Technology is just one part of the education equation. 
 

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Technology ≠ Education

A version of this article was previously published on the Massachusetts Nonprofit Network. 

Editor’s note: While this article is not technical in nature, you should read it if you are involved in IT security, auditing, and management of organizations that may participate in strategic planning and business activities where considerations of compliance and controls is required.

As we find ourselves in a fast-moving, strong business growth environment, there is no better time to consider the controls needed to enhance your IT security as you implement new, high-demand technology and software to allow your organization to thrive and grow. Here are five risks you need to take care of if you want to build or maintain strong IT security.

1. Third-party risk management―It’s still your fault

We rely daily on our business partners and vendors to make the work we do happen. With a focus on IT, third-party vendors are a potential weak link in the information security chain and may expose your organization to risk. However, though a data breach may be the fault of a third-party, you are still responsible for it. Potential data breaches and exposure of customer information may occur, leaving you to explain to customers and clients answers and explanations you may not have. 

Though software as a service (SaaS) providers, along with other IT third-party services, have been around for well over a decade now, we still neglect our businesses by not considering and addressing third-party risk. These third-party providers likely store, maintain, and access company data, which could potentially contain personally identifiable information (names, social security numbers, dates of birth, addresses), financial information (credit cards or banking information), and healthcare information of your customers. 

While many of the third-party providers have comprehensive security programs in place to protect that sensitive information, a study in 2017 found that 30% of data breaches were caused by employee error or while under the control of third-party vendors.1  This study reemphasizes that when data leaves your control, it is at risk of exposure. 

In many cases, procurement and contracting policies likely have language in contracts that already establish requirements for third-parties related to IT security; however the enforcement of such requirements and awareness of what is written in the contract is not enforced or is collected, put in a file, and not reviewed. What can you do about it?

Improved vendor management

It is paramount that all organizations (no matter their size) have a comprehensive vendor management program that goes beyond contracting requirements in place to defend themselves against third-party risk which includes:

  1. An inventory of all third-parties used and their criticality and risk ranking. Criticality should be assigned using a “critical, high, medium or low” scoring matrix. 
  2. At time of onboarding or RFP, develop a standardized approach for evaluating if potential vendors have sufficient IT security controls in place. This may be done through an IT questionnaire, review of a Systems and Organization Controls (SOC report) or other audit/certifications, and/or policy review. Additional research may be conducted that focuses on management and the company’s financial stability. 
  3. As a result of the steps in #2, develop a vendor risk assessment using a high, medium and low scoring approach. Higher risk vendors should have specific concerns addressed in contracts and are subject to more in depth annual due diligence procedures. 
  4. Reporting to senior management and/or the board annually on the vendors used by the organization, the services they perform, their risk, and ways the organization monitors the vendors. 

2. Regulation and privacy laws―They are coming 

2018 saw the implementation of the European Union’s General Data Privacy Regulation (GDPR) which was the first major data privacy law pushed onto any organization that possesses, handles, or has access to any citizen of EU’s personal information. Enforcement has started and the Information Commissioner’s Office has begun fining some of the world’s most famous companies, including substantial fines to Marriott International and British Airways of $125 million and $183 million Euros, respectively.2  Gone are the days where regulations lacked the teeth to force companies into compliance. 

With thanks to other major data breaches where hundreds of millions’ consumers private information was lost or obtained (e.g., Experian), more regulation is coming. Although there is little expectation of an American federal requirement for data protection, individual states and other regulating organizations are introducing requirements. Each new regulation seeks to protect consumer privacy but the specifics and enforcement of each differ. 

Expected to be most impactful in 2019 is the California Consumer Privacy Act,  which applies to organizations that handle, collect, or process consumer information and do business in the state of California (you do not have to be located in CA to be under the umbrella of enforcement).

In 2018, Maine passed the toughest law on telecommunications providers for selling consumer information. Massachusetts’ long standing privacy and data breach laws were amended with stronger requirements in January of 2019. Additional privacy and breach laws are in discussion or on the table for many states including Colorado, Delaware, Ohio, Oregon, Ohio, Vermont, and Washington, amongst others.      

Preparation and awareness are key

All organizations, no matter your line of business must be aware of and understand current laws and proposed legislation. New laws are expected to not only address the protection of customer data, but also employee information. All organizations should monitor proposed legislation and be aware of the potential enforceable requirements. The good news is that there are a lot of resources out there and, in most cases, legislative requirements allow for grace periods to allow organizations to develop a complete understanding of proposed laws and implement needed controls. 

3. Data management―Time to cut through the clutter 

We all work with people who have thousands of emails in their inbox (in some cases, dating back several years). Those users’ biggest fears may start to come to fruition―that their “organizational” approach of not deleting anything may come to an end with a simple email and data retention policy put in place by their employer. 

The amount of data we generate in a day is massive. Forbes estimates that we generate 2.5 quintillion bytes of data each day and that 90% of all the world’s data was generated in the last two years alone.3 While data is a gold mine for analytics and market research, it is also an increasing liability and security risk. 

Inc. Magazine says that 73% of the data we have available to us is not used.4 Within that data could be personally identifiable information (such as social security numbers, names, addresses, etc.); financial information (bank accounts, credit cards etc.); and/or confidential business data. That data is valuable to hackers and corporate spies and in many cases data’s existence and location is unknown by the organizations that have it. 

In addition to the security risk that all this data poses, it also may expose an organization to liability in the event of a lawsuit of investigation. Emails and other communications are a favorite target of subpoenas and investigations and should be deleted within 90 days (including deleted items folders). 

Take an inventory before you act

Organizations should first complete a full data inventory and understand what types of data they maintain and handle, and where and how they store that data. Next, organizations can develop a data retention policy that meets their needs. Utilizing backup storage media may be a solution that helps reduce the need to store and maintain a large amount of data on internal systems. 

4. Doing the basics right―The simple things work 

Across industries and regardless of organization size, the most common problem we see is the absence of basic controls for IT security. Every organization, no matter their size, should work to ensure they have controls in place. Some must-haves:

  • Established IT security policies
  • Routine, monitored patch management practices (for all servers and workstations)
  • Change management controls (for both software and hardware changes)
  • Anti-virus/malware on all servers and workstations
  • Specific IT security risk assessments 
  • User access reviews
  • System logging and monitoring 
  • Employee security training

Go back to the basics 

We often see organizations that focus on new and emerging technologies, but have not taken the time to put basic security controls in place. Simple deterrents will help thwarting hackers. I often tell my clients a locked car scares away most ill-willed people, but a thief can still smash the window.  

Smaller organizations can consider using third-party security providers, if they are not able to implement basic IT security measures. From our experience, small organizations are being held to the same data security and privacy expectations by their customers as larger competitors and need to be able to provide assurance that controls are in place.  

5. Employee retention and training 

Unemployment rates are at an all-time low, and the demand for IT security experts at an all-time high. In fact, Monster.com reported that in 2019 the unemployment rate for IT security professionals is 0%.5 

Organizations should be highly focused on employee retention and training to keep current employees up-to-speed on technology and security trends. One study found that only 15% of IT security professionals were not looking to switch jobs within one year.6  

Surprisingly, money is not the top factor for turnover―68% of respondents prioritized working for a company that takes their opinions seriously.6 

For years we have told our clients they need to create and foster a culture of security from the top down, and that IT security must be considered more than just an overhead cost. It needs to align with overall business strategy and goals. Organizations need to create designated roles and responsibilities for security that provide your security personnel with a sense of direction―and the ability to truly protect the organization, their people, and the data. 

Training and support goes a long way

Offering training to security personnel allows them to stay abreast of current topics, but it also shows those employees you value their knowledge and the work they do. You need to train technology workers to be aware of new threats, and on techniques to best defend and protect from such risks. 

Reducing turnover rate of IT personnel is critical to IT security success. Continuously having to retrain and onboard employees is both costly and time-consuming. High turnover impacts your culture and also hampers your ability to grow and expand a security program. 

Making the effort to empower and train all employees is a powerful way to demonstrate your appreciation and support of the employees within your organization—and keep your data more secure.  

Our IT security consultants can help

Ensuring that you have a stable and established IT security program in place by considering the above risks will help your organization adapt to technology changes and create more than just an IT security program, but a culture of security minded employees. 

Our team of IT security and control experts can help your organization create and implement controls needed to consider emerging IT risks. For more information, contact the team. 
 

Sources:
[1] https://iapp.org/news/a/surprising-stats-on-third-party-vendor-risk-and-breach-likelihood/  
[2] https://resources.infosecinstitute.com/first-big-gdpr-fines/
[3] https://www.forbes.com/sites/bernardmarr/2018/05/21/how-much-data-do-we-create-every-day-the-mind-blowing-stats-everyone-should-read/#458b58860ba9
[4] https://www.inc.com/jeff-barrett/misusing-data-could-be-costing-your-business-heres-how.html
[5] https://www.monster.com/career-advice/article/tech-cybersecurity-zero-percent-unemployment-1016
[6] https://www.securitymagazine.com/articles/88833-what-will-improve-cyber-talent-retention

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Five IT risks everyone should be aware of

Editor’s note: If you are a higher education CFO, CIO, CTO or other C-suite leader, this blog is for you.

The Gramm-Leach-Bliley Act (GLBA) has been in the news recently as the Federal Trade Commission (FTC) has agreed to extend a deadline for public comment regarding proposed changes to the Safeguards Rule. Here’s what you need to know.

GLBA, also known as the Financial Modernization Act, is a 1999 federal law providing rules to financial institutions for protecting consumer information. Colleges and universities fall under this act because they conduct financial activities (e.g., administration of financial aid, loans, and other financial services).

Under the Safeguards Rule financial Institutions must develop, implement, and maintain a comprehensive information security program that consists of safeguards to handle customer information.

Proposed changes

The FTC is proposing five modifications to the Safeguards Rule. The new act will:

  • Provide more detailed guidance to impacted institutions regarding how to develop and implement specific aspects of an overall information security program.
  • Improve the accountability of an institution’s information security programs.
  • Exempt small business from certain requirements.
  • Expand the definition of “financial institutions” to include entities engaged in activities that the Federal Reserve Board determines to be incidental to financial activities.
  • Propose to include the definition of “financial institutions” and related examples in the rule itself rather than cross-reference them from a related FTC rule (Privacy of Consumer Financial Information Rule).

Potential impacts for your institution

The Federal Register, Volume 84, Number 65, published the notice of proposed changes that once approved by the FTC would add more prescriptive rules that could have significant impact on your institution. For example, these rules would require institutions to:

  1. Expand existing security programs with additional resources.
  2. Produce additional documentation.
  3. Create and implement additional policies and procedures.
  4. Offer various forms of training and education for security personnel.

The proposed rules could require institutions to increase their commitment in time and staffing, and may create hardships for institutions with limited or challenging resources.

Prepare now

While these changes are not final and the FTC is requesting public comment, here are some things you can do to prepare for these potential changes:

  • Evaluate whether your institution is compliant to the current Safeguards Rule.
  • Identify gaps between current status and proposed changes.
  • Perform a risk assessment.
  • Ensure there is an employee designated to lead the information security program.
  • Monitor the FTC site for final Safeguard Rules updates.

In the meantime, reach out to us if you would like to discuss the impact GLBA will have on your institution or if you would like assistance with any of the recommendations above. You can view a comprehensive list of potential changes here.

Source: Federal Trade Commission. Safeguards Rule. Federal Register, Vol. 84, No. 65. FTC.gov. April 4, 2019. https://www.ftc.gov/enforcement/rules/rulemaking-regulatory-reform-proceedings/safeguards-rule

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Higher ed: GLBA is the new four-letter word, but it's not as bad as you think

In light of the recent cyberattacks in higher education across the US, more and more institutions are finding themselves no longer immune to these activities. Security by obscurity is no longer an effective approach—all  institutions are potential targets. Colleges and universities must take action to ensure processes and documentation are in place to prepare for and respond appropriately to a potential cybersecurity incident.

What are some examples of incidents that managers need to prepare for?

Examples range from external breaches and insider threats to instances of malfeasance or incompetence. Different types of incidents lead to the same types of results—yet you can’t have a broad view of incidents. Managers should work with their teams to create incident response plans that reflect the threats associated with higher education institutions. A handful of general incident response plans isn’t going to cut it.

Managers need to work with their teams to develop a specific incident response plan for each specific type of incident. Why? Well, think of it this way: Your response to a careless employee should be different from your response to a malicious employee, for a whole host of legal reasons. Incident response is not a cookie-cutter process. In fact, it is quite the opposite. This is one of the reasons I highly suggest security teams include staff members outside of IT. When you’re responding to incidents, you want people who can look at a problem or situation from an external perspective, not just a technical or operational perspective within IT. These team members can help answer questions such as, what does the world see when they look at our institution? What institutional information might be valuable to, or targeted by, malicious actors? You’ll get some valuable fresh perspectives.

How short or long should the typical incident response plan be?

I often see good incident response plans no more than three or four pages in length. However, it is important that incident response plans are task oriented, so that it is clear who does what next. And when people follow an incident response plan, they should physically or digitally check off each activity, then record each activity.

What system or software do you recommend for recording incidents and responses?

There are all types of help desk software you can use, including free and open source software. I recommend using help desk software with workflow capabilities, so your team can assign and track tasks.

Any other tips for developing incident response plans?

First, managers should work with, and solicit feedback from across the academic and administrative areas within the institution when developing incident response plans. If you create these documents in a vacuum, they will be useless.

Second, managers and their teams should take their time and develop the most “solid” incident response plans possible. Don’t rush the process. The effectiveness of your incident response plans will be critical in assessing your institution’s ability to survive a breach. Because of this, you should be measuring your response plans through periodic testing, like conducting tabletop exercises.

Third, keep your students and external stakeholders in mind when developing these plans. You want to make sure external communications are consistent, accurate, and within the legal requirements for your institution. The last thing you want is students and stakeholders receiving conflicting messages about the incident. 

Are there any decent incident response plans in the public domain that managers and their teams can adapt for their own purposes?

Yes. My default reference is the National Institute of Standards and Technology (NIST). NIST has many special publications that describe the incident response process, how to develop a solid plan, and how to test your plan.

Should institutions have dedicated incident response teams?

Definitely. Institutions should identify and staff teams using internal resources. Some institutions may want to consider hiring a reputable third party to act as an incident response team. The key with hiring a third party? Don’t wait until an incident occurs! If you wait, you’re going to panic, and make panic-based decisions. Be proactive and hire a third party on retainer.

That said, institutions should consider hiring a third party on an annual basis to review incident response plans and processes. Why? Because every institution can grow complacent, and complacency kills. A third party can help gauge the strengths and weaknesses of your internal incident response teams, and provide suggestions for general or specific training. A third party can also educate your institution about the latest and greatest cyber threats.

Should managers empower their teams to conduct internal “hackathons” in order to test incident response?

Sure! It’s good practice, and it can be a lot of fun for team members. There are a few caveats. First, don’t call it a hackathon. The word can elicit negative or concerned reactions. Call it “active testing” or “continuous improvement exercises.” These activities allow team members to think creatively, and are opportunities for them to boost their cybersecurity knowledge. Second, be prepared for pushback. Some managers worry if team members gain more cybersecurity skills, then they’ll eventually leave the institution for another, higher-paying job. I think you should be committed to the growth of your team members―it’ll only make your institution more secure.

What are some best practices managers should follow when reporting incidents to their leadership?

Keep the update quick, brief, and to the point. Leave all the technical jargon out, and keep everything in an institutional context. This way leadership can grasp the ramifications of the event and understand what matters. Be prepared to outline how you’re responding and what actions leadership can take to support the incident response team and protect the institution. In the last chapter, I mentioned what I call the General Colin Powell method of reporting, and I suggest using that method when informing leadership. Tell them what you know, what you don’t know, what you think, and what you recommend. Have answers, or at least a plan.

How much institution-wide communication should there be about incidents?

That’s a great question, but a tough one to answer. Transparency is good, but it can also unintentionally lead to further incidents. Do you really want to let your whole institution know about an exploitable weakness? Also, employees can spread information about incidents on social media, which can actually lead to the spread of misinformation. If you are in doubt about whether or not to inform the entire institution about an incident, refer to your Legal Department. In general, institution-wide communication should be direct: We’ve had an incident; these are the facts; this is what you are allowed to say on social media; and this is what you’re not allowed to say on social media.

Another great but tough question: When do you tell the public about an incident? For this type of communication, you’re going to need buy-in from various sources: senior leadership, Legal, HR, and your PR team or external PR partners. You have to make sure the public messaging is consistent. Otherwise, citizens and the media will try to poke holes in your official story. And that can lead to even more issues.

What are the key takeaways for higher education leaders?

Here are key takeaways to help higher education leaders prepare for and respond appropriately to cybersecurity incidents:

  1. Understand your institution’s current cybersecurity environment. 
    Questions to consider: Do you have Chief Information Security Officer (CISO) and/or a dedicated cybersecurity team at your institution? Have you conducted the appropriate audits and assessments to understand your institution’s vulnerabilities and risks?
  2. Ensure you are prepared for cybersecurity incidents. 
    Questions to consider: Do you have a cybersecurity plan with the appropriate response, communication, and recovery plans/processes? Are you practicing your plan by walking through tabletop exercises? Do you have incident response teams?

Higher education continues to face growing threats of cybersecurity attacks – and it’s no longer a matter of if, but when. Leaders can help mitigate the risk to their institutions by proactively planning with incident response plans, communication plans, and table-top exercises. If you need help creating an incident response plan or wish to speak to us regarding preparing for cybersecurity threats, please reach out to us.
 

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Cyberattacks in higher education—How prepared are you?

Focus on the people: How higher ed institutions can successfully make an ERP system change

The enterprise resource planning (ERP) system is the heart of an institution’s business, maintaining all aspects of day-to-day operations, from student registration to staff payroll. Many institutions have used the same ERP systems for decades and face challenges to meet the changing demands of staff and students. As new ERP vendors enter the marketplace with new features and functionality, institutions are considering a change. Some things to consider:

  1. Don’t just focus on the technology and make change management an afterthought. Transitioning to a new ERP system takes considerable effort, and has the potential to go horribly wrong if sponsorship, good planning, and communication channels are not in place. The new technology is the easy part of a transition—the primary challenge is often rooted in people’s natural resistance to change.  
  2. Overcoming resistance to change requires a thoughtful and intentional approach that focuses on change at the individual level. Understanding this helps leadership focus their attention and energy to best raise awareness and desire for the change.
  3. One effective tool that provides a good framework for successful change is the Prosci ADKAR® model. This framework has five distinct phases that align with ERP change:

These phases provide an approach for developing activities for change management, preparing leadership to lead and sponsor change and supporting employees through the implementation of the change.

The three essential steps to leveraging this framework:

  1. Perform a baseline assessment to establish an understanding of how ready the organization is for an ERP change
  2. Provide sponsorship, training, and communication to drive employee adoption
  3. Prepare and support activities to implement, celebrate, and sustain participation throughout the ERP transition

Following this approach with a change management framework such as the Prosci ADKAR® model can help an organization prepare, guide, and adopt ERP change more easily and successfully. 

If you’re considering a change, but need to prepare your institution for a healthy ERP transition using change management, chart yourself on this ADKAR framework—what is your organization’s change readiness? Do you have appropriate buy-in? What problems will you face?

You now know that this framework can help your changes stick, and have an idea of where you might face resistance. We’re certified Prosci ADKAR® practitioners and have experience guiding Higher Ed leaders like you through these steps. Get in touch—we’re happy to help and have the experience and training to back it up. Please contact the team with any questions you may have.

1Prosci ADKAR®from http://www.prosci.com

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Perspectives of an Ex-CIO

“The world is one big data problem,” says MIT scientist and visionary Andrew McAfee.

That’s a daunting (though hardly surprising) quote for many in data-rich sectors, including higher education. Yet blaming data is like blaming air for a malfunctioning wind turbine. Data is a valuable asset that can make your institution move.

To many of us, however, data remains a four-letter word. The real culprit behind the perceived data problem is our handling and perception of data and the role it can play in our success—that is, the relegating of data to a select, responsible few, who are usually separated into hardened silos. For example, a common assumption in higher education is that the IT team can handle it. Not so. Data needs to be viewed as an institutional asset, consumed by many and used by the institution for the strategic purposes of student success, scholarship, and more.

The first step in addressing your “big” data problem? Data governance.

What is data governance?

There are various definitions, but the one we use with our clients is “the ongoing and evolutionary process driven by leaders to establish principles, policies, business rules, and metrics for data sharing.”

Please note that the phrase “IT” does not appear anywhere in this definition.

Why is data governance necessary? For many reasons, including:

  1. Data governance enables analytics. Without data governance, it’s difficult to gain value from analytics initiatives which will produce inconsistent results. A critical first step in any data analytics initiative is to make sure that definitions are widely accepted and standards have been established. This step allows decision makers to have confidence in the data being analyzed to describe, predict, and improve operations.
  2. Data governance strengthens privacy, security, and compliance. Compliance requirements for both public and private institutions constantly evolve. The more data-reliant your world becomes, the more protected your data needs to be. If an organization does not implement security practices as part of its data governance framework, it becomes easier to fall out of compliance. 
  3. Data governance supports agility. How many times have reports for basic information (part-time faculty or student FTEs per semester, for example) been requested, reviewed, and returned for further clarification or correction? And that’s just within your department! Now add multiple requests from the perspective of different departments, and you’re surely going through multiple iterations to create that report. That takes time and effort. By strengthening your data governance framework, you can streamline reporting processes by increasing the level of trust you have in the information you are seeking. Understanding the value of data governance is the easy part. The real trick is implementing a sustainable data governance framework that recognizes that data is an institutional asset and not just a four-letter word.
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Data is a four-letter word. Governance is not.