Trusting privileged accounts in the age of data breaches

Read this if you are a bank with over $1 billion in assets.

It’s no secret COVID-19 has had a substantial impact on the economy. As unemployment soared and the economy teetered on the edge of collapse, unprecedented government stimulus attempted to stymie the COVID-19 tidal wave. One tool used by the government was the creation of the Paycheck Protection Program (PPP). Part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the PPP initially authorized the lending of $349 billion to encourage businesses to keep workers employed and cover certain operating expenses during the coronavirus pandemic. The PPP was then extended through August 8, 2020 with an additional $310 billion authorized.

Many financial institutions scrambled to free up resources and implement processes to handle the processing of PPP loan applications. However, such underwriting poses unique challenges for financial institutions. PPP loans are 100% guaranteed by the US Small Business Administration (SBA) if the borrowers meet certain criteria. Establishing appropriate controls over the loan approval and underwriting process is more a matter of ensuring compliance with the PPP, rather than ensuring the borrower can repay their loan.

Federal Deposit Insurance Corporation Improvement Act of 1991 compliance 

Banks with total assets over $1 billion as of the beginning of their fiscal year must comply with the Federal Deposit Insurance Corporation Improvement Act of 1991 (FDICIA). Amongst other things, FDICIA requires management perform an assessment and provide a resulting attestation on the operating effectiveness of the bank’s internal controls over financial reporting (ICFR) as of the bank’s fiscal year-end. Although this attestation is as of year-end, management must perform testing of the bank’s ICFR throughout the bank’s fiscal year to obtain sufficient evidence regarding the operating effectiveness of ICFR as of year-end. Key controls over various transaction cycles are typically housed in a matrix, making it easy for management and other users, such as independent auditors, to review a bank’s key ICFR. 

Internal control documentation

If the process for originating PPP loans is different from the bank’s process for traditional loan products, it’s likely the internal controls surrounding this process is also different. Given that $659 billion in PPP loans have been granted to date, it is possible PPP loans may be material to individual banks’ balance sheets. If PPP loans are material to your bank’s balance sheet, you should consider the controls that were put in place. If the controls are deemed to be different from those already documented for other types of loans, you should document such controls as new controls in your FDICIA matrix and test accordingly.

As noted earlier, the risks a financial institution faces with PPP loans are likely different from traditional underwriting. If these unique risks could impact amounts reported in the financial statements, it’s smart to address them through the development of internal controls. Banks should assess their individual situations to identify any risks that may have not previously existed. For instance, given the volume of PPP loans originated in such a short period of time, quality control processes may have been stretched to their limits. The result could be PPP loans inaccurately set up in the loan accounting system or loan files missing key information. Depending on the segregation of duties, the risk could even be the creation of fictitious PPP loans. A detective internal control that could address inaccurate loan setup would be to scan a list of PPP loans for payment terms, maturity dates, or interest rates that appear to be outliers. Given the relatively uniform terms for PPP loans, any anomalies should be easily identifiable. 

Paycheck Protection Program loan fees

Aside from internal controls surrounding the origination of PPP loans, banks may also need to consider documenting internal controls surrounding PPP loan fees received by the SBA. Although the accounting for such fees is not unique, given the potential materiality to the income statement, documenting such a control, even if it is merely addressing the fees in an already existing control, exhibits that management has considered the impact PPP loan fees may have on their ICFR. 

The level of risk associated with PPP loan fees may differ from institution to institution. For instance, a bank that is calculating its PPP loan fees manually rather than relying on the loan accounting system to record and subsequently recognize income on these fees, inherently has more risk. This additional level of risk will need to be addressed in the development and documentation of internal controls. In this example, a periodic recalculation of PPP loan fees on a sample basis, including income recognition, may prove to be a sufficient internal control.

With the calendar year-end fast approaching, it is time to take a hard look at those FDICIA matrices, if you haven’t already done so:

• Consider what has changed at your bank during the fiscal year and how those changes have impacted the design and operation of your internal controls. 
• Ensure that what is happening in practice agrees to what is documented within your FDICIA matrix. 
• Ensure that new activities, such as the origination of PPP loans, are adequately documented in your FDICIA matrix. 

With Congress considering another round of PPP loans, there is no time like the present to make sure your bank is ready from an ICFR perspective. If you have questions about your specific situation, or would like more information, please contact the FDICIA compliance team. 

Read this if you are a Chief Executive Officer, Chief Financial Officer, Chief Risk Officer, Chief Information Officer, or Controller.

While COVID-19 has forced many of us into a remote work environment, we also have to deal with the challenges that come along with it. The stark contrast between an office environment and one that potentially involves working in isolation can be a difficult adjustment. Office kitchen conversations have evolved into conversations with pets, our newest co-workers. A quick, in-person question has now turned into an email, phone, or video call. And job responsibilities expand as we try to not only juggle work but also ensure our children focus on school work―and don’t destroy the house. 

Not only has this forced environment caused social challenges, it has also opened the door for internal control challenges, as  internal controls designed to operate effectively in an office environment may not be ideal for a remote workplace. Even ones that are appropriately designed, may prove to be operating ineffectively in this new environment. Let’s take a look at some internal control challenges, and potential solutions, faced by working in a remote environment.

Establishing a remote control environment

Exercising appropriate tone at the top and establishing appropriate oversight can be challenging with a remote workforce. Ethics and governance policies play an important role in setting clear expectations about workplace behaviors. But, a workforce is much more apt to follow a leadership team’s example rather than a policy. All of those office conversations, even the conversations that are not work related, help set an expectation of appropriate and inappropriate behaviors. These conversations often happen naturally in the office via a quick conversation in passing in the hallway or a late-Friday happy hour with your department. However, these interactions do not naturally occur in a remote workplace. Leadership and department heads should make an active effort to maintain communication with their workforce. Some things to consider:

• Send out weekly emails to the entire department and possibly more personal, one-on-one videoconferences or phone calls between your department heads or managers and individual members of their teams.
• These department-wide emails should stress the importance of communication as well as continuing to produce high quality work and maintaining accountability. 
• One-on-one meetings should be used to check in with employees to ensure their work needs are being met. 

Employees will most likely have many suggestions to improve their new work environment, including suggestions on how to improve communication amongst team members. 

The power of video

Videoconferencing also provides a great opportunity to stay connected. Virtual happy hours simulate an in-person happy hour. This is a great way to check-in with team members and show that, although people are out of sight, they are not out of mind. Town hall-type meetings can also be explored. Your leadership team can solicit open discussion. Agenda items may include office status updates, technological considerations, and an opportunity for employees to openly discuss current challenges due to working in a remote environment. Employees are going to have anxiety about the current environment. These meetings can help put employees at ease.

Risk assessment

Internal control environments are constantly evolving. Employees leave. Software is updated.  Offered services and products change. The list goes on. However, it is unprecedented that an internal control environment has changed so rapidly. Given these unprecedented times, there is potential for higher risk of fraud, internally and externally. Those responsible for designing internal controls (control owners) should reassess your company’s environment. Although internal controls can be designed in a manner in which they operate effectively regardless of the circumstances, it is possible there are unintended changes to processes that have occurred. 

For instance, let’s say the employee responsible for reviewing loan file maintenance changes is now working an alternative work schedule due to personal obligations. This employee does not have the ability to make loan file changes; therefore, segregation of duties has never been an issue. An employee within loan servicing has agreed to take some of the employee’s responsibilities and is now reviewing some of the loan file maintenance changes, which has put this employee in a position to review some of their own changes. 

Furthermore, some internal controls that require employees be at a physical location to operate may also be compromised, such as inventory cycle counts. If these controls are unable to operate, control owners will need to consider the impacts on the affected transaction areas, and if there are compensating controls that can be designed to alleviate some of the control risk.

Control activities

Accounts payable and check signing

The accounts payable and cash disbursement process will most likely be upended as a result of your new remote environment. Bills received through the mail will need to be scanned to the accounts payable clerk for entry into the accounting system. Some offices have designated certain personnel responsible for checking mail on an infrequent basis, for instance, weekly. Check signing may also prove to be a challenge as blank check stock may be inaccessible. Electronic receipt of invoices and signing of checks, as well as the use of wire and ACH transfers, lend themselves as feasible solutions. Email approvals may suffice when multiple signers are needed to approve high dollar disbursements.

Segregation of duties

As mentioned above, it is possible processes have inadvertently changed, exposing certain internal controls to ineffectiveness. Segregation of duties may become difficult as employees shift to alternative work schedules or have other issues. Maintaining segregation of duties should be a top priority for control owners and is something that should be constantly assessed as circumstances change. Challenging times may make segregation of duties difficult and may force you to get creative by requesting employees perform duties they are not otherwise accustomed to performing.

Digital sign-offs

You should also consider the manner in which you document the completion of controls. Control owners should be cautious about the integrity of an employee’s initials simply typed onto a digital document, as any employee can perform this task. Digital signatures, which require an employee to enter credentials prior to signing, enhance the integrity of a sign-off and are often time stamped. Digital signatures may also “lock down” the document, prohibiting any changes to the signed document.

Timely review

Given the circumstances, it is not unreasonable that preparation and review may take longer than under normal circumstances. Even if additional time is granted for the preparation and review of documents, you should consider the implications this has on the transaction class as a whole. The longer it takes to complete a control, the greater the consequences may be if you identify an error. For instance, the impact of an incorrect change to a loan rate index can be substantial if not identified timely. If identified quickly, you can avoid consequences later.

Information and communication

For many companies that have moved from a paper to a digital environment, sharing of information should not be an issue. However, for those that still operate in a mostly paper environment, performing tasks and sharing information with team members may prove to be difficult. And, those without the capability of scanning and sending documents from home could compromise a specific internal control altogether. Being forced to work remotely may be the perfect excuse to move paper processes into a digital format.

Monitoring

Monitoring your internal control environment is of the utmost importance given these significant changes. Frequent conversations should be had with control owners to ensure changes to processes do not render controls ineffective. Identified gaps in internal controls should be addressed proactively. Provide control owners with the opportunity to discuss changes to control processes with Internal Audit or Risk Management so such departments can consider the impact of changes on internal control. This also gives these departments the opportunity to cover any resulting gaps.

Permanent changes

Once the remote workplace requirements end, the effects of working in such an environment will not. There are many benefits and efficiencies to be found in working remotely. As people have now been forced to work in such an environment, they will be more apt to continue to do so. Therefore, let’s take this opportunity to revise processes and internal controls to be “remote workplace” compatible. This will provide a long-lasting impact to your organization far beyond the pandemic. 
 

Editor’s note: Please read this if you are a not-for-profit board member, CFO, or any other decision maker within a not-for-profit.

In a time where not-for-profit (NFP) organizations struggle with limited resources and a small back office, it is important not to overlook internal audit procedures. Over the years, internal audit departments have been one of the first to be cut when budgets are tight. However, limited resources make these procedures all the more important in safeguarding the organization’s assets. Taking the time to perform strategic internal audit procedures can identify fraud, promote ethical behavior, help to monitor compliance, and identify inefficiencies. All of these lead to a more sustainable, ethical, and efficient organization. 

Internal audit approaches

The internal audit function can take on many different forms, depending on the size of the organization. There are options between the dedicated internal audit department and doing nothing whatsoever. For example:

• A hybrid approach, where specific procedures are performed by an internal team, with other procedures outsourced. 
• An ad hoc approach, where the board or management directs the work of a staff member.

The hybrid approach will allow the organization to hire specialists for more technical tasks, such as an in-depth financial analysis or IT risk assessment. It also recognizes internal staff may be best suited to handle certain internal audit functions within their scope of work or breadth of knowledge. This may add costs but allows you to perform these functions otherwise outside of your capacity without adding significant burden to staff. 

The ad hoc approach allows you to begin the work of internal audit, even on a small scale, without the startup time required in outsourcing the work. This approach utilizes internal staff for all functions directed by the board or management. This leads to the ad-hoc approach being more budget friendly as external consultants don’t need to be hired, though you will have to be wary of over burdening your staff.

With proper objectivity and oversight, you can perform these functions internally. To bring the process to your organization, first find a champion for the project (CFO, controller, compliance officer, etc.) to free up staff time and resources in order to perform these tasks and to see the work through to the end. Other steps to take include:

1. Get the audit/finance committee on board to help communicate the value of the internal audit and review results of the work
2. Identify specific times of year when these processes are less intrusive and won’t tax staff 
3. Get involved in the risk management process to help identify where internal audit can best address the most significant risks at the organization
4. Leverage others who have had success with these processes to improve process and implementation
5. Create a timeline and maintain accountability for reporting and follow up of corrective actions

Once you have taken these steps, the next thing to look at (for your internal audit process) is a thoughtful and thorough risk assessment. This is key, as the risk assessment will help guide and focus the internal audit work of the organization in regard to what functions to prioritize. Even a targeted risk assessment can help, and an organization of any size can walk through a few transaction cycles (gift receipts or payroll, for example) and identify a step or two in the process that can be strengthened to prevent fraud, waste, and abuse.  

Here are a few examples of internal audit projects we have helped clients with:

• Payroll analysis—in-depth process mapping of the payroll cycle to identify areas for improvement
• Health and education facilities performance audit—analysis of various program policies and procedures to optimize for compliance
• Agreed upon procedures engagement—contract and invoice/timesheet information review to ensure proper contractor selection and compliant billing and invoicing procedures 

Internal audits for companies of all sizes

Regardless of size, your organization can benefit from internal audit functions. Embracing internal audit will help increase organizational resilience and the ability to adapt to change, whether your organization performs internal audit functions internally, outsources them, or a combination of the two. For more information about how your company can benefit from an internal audit, or if you have questions, contact us. 

Editor’s note: Read this if you are a Chief Executive Officer, Chief Financial Officer, Chief Risk Officer, Chief Information Officer, or Controller.

Last month, the Office of the Comptroller of the Currency (OCC) issued its Semiannual Risk Perspective for Fall 2019. The report addresses key issues facing banks and focuses on those that pose threats to their safety and soundness. According to the report:

• Bank financial performance is strong due to a favorable credit environment and the longest economic expansion in U.S. history.
• Capital levels have reached historical highs.
• Return on equity was above its 2006 pre-crisis level for the first time at 12.7%.
• Net income grew 8.22% from the same period a year ago; however, net interest income grew only 4%, as loan growth is below historical averages and an increasing number of banks are facing a flat or declining net interest margin.
• There is continued weakness in residential and commercial real estate loan growth.
• Delinquent and nonperforming loans remain below their long-term averages.

Banks can thrive even with economic uncertainty

While these trends indicate that 2019 was by and large an excellent year, banks cannot afford to be complacent, as 2019 also saw increasing risks to the industry. For instance, in 2019 there was much discussion of the future cessation of the London InterBank Offer Rate (LIBOR). The OCC has indicated it will increase its regulatory oversight regarding the anticipated cessation, to ensure banks assess their exposure to LIBOR and are appropriately planning their transition from the widely used benchmark rate. The Financial Accounting Standards Board (FASB) is also working on a project to address accounting issues that could arise from the transition from LIBOR.

And, although 2019 continued the longest economic expansion in US history, economic uncertainty exists due to, in part, the US-China trade conflict and ongoing Brexit discussions. This economic uncertainty has caused volatility in the interest rate environment. Aside from the yield curve inverting in 2019, banks also saw the Federal Funds target rate increase 25 basis points prior to decreasing 50 basis points. Given the typically asset-sensitive nature of banks’ balance sheets, the current interest rate environment will also put pressure on net interest margins. The current volatility of interest rates has caused the OCC to conclude interest rate risk is currently at heightened levels. 

Net interest income continues to be the most significant driver of net revenues for community banks, comprising nearly 80% of net revenues. With a difficult interest rate environment and lackluster loan growth in residential and commercial real estate, banks may face a difficult path ahead. Banks should tread cautiously, especially if this uncertainty persists. Asset-liability management will need be a significant focus (more than usual) as banks try to position themselves to not only maintain profitability through this uncertainty, but also come out stronger than before. Specifically, if lower rates persist, asset growth will need be a priority over deposit growth to maintain profitability at lower net interest margins. If loan growth continues to wane, this will prove to be difficult.

Innovations to compete with new lending sources

Adding to the list of threats to performance is the increasing amount of alternative financial resources available to borrowers. Banks have traditionally been the only source of credit for borrowers. However, technology has rapidly changed that landscape. Person-to-person (P2P) lending (also known as crowd lending, or social lending), allows people to borrow funds directly from another person, cutting out traditional lending sources (banks). Additionally, blockchain technology, if the hype is accurate, has the potential to eliminate the need of a financial intermediary altogether. 

Banks are adapting to this competition and to customers looking for more convenience and alternative services by offering new, unique services that differentiate themselves from others and provide added value to the customer. Banks have delivered through remote deposit, ATMs, and interactive teller machines (ITMs). Banks will need to continue to adopt innovative services to remain competitive. 

For instance, banks could offer video conferencing services, in which customers could have a live conversation with a bank representative through their smartphone. This convenience would allow a customer to conduct a transaction, such as apply for a loan, from the convenience of their home, while still maintaining human interaction throughout the transaction. Such a service would help banks compete with digital channels offered by non-banks, such as Quicken Loans, which is now the largest mortgage originator in the United States.

Strategies to protect against technological risks

These services all require the use of existing and new technologies, which have caused banks to hold more personally identifiable information (PII) digitally across an increasing number of digital platforms. As noted by the OCC, this digital exposure has created persistent cybersecurity risks for banks. Adopting a robust cybersecurity framework is no longer an option. 

Banks should bring cybersecurity to the forefront of their strategic planning. Any strategic plan must consider cybersecurity implications, as a single disaster can be detrimental to a bank’s reputation. And, given this rapidly changing environment, the cybersecurity conversation must be ongoing through relevant bank committees and the board of directors.

Furthermore, these technological solutions require partnerships with businesses that banks would not traditionally partner with. Financial technology (fintech) companies don’t just pose as a competitor to traditional banks. Many fintech companies are offering their technological solutions to traditional banks. However, outsourcing technological solutions to fintech companies and other businesses does not relieve a bank from performing its own due diligence and ensuring those companies meet the bank’s standards. 

Banks should evaluate potential vendors to ensure they comply with the bank’s vendor management policy. Since environments are constantly changing, this evaluation should be ongoing. Many vendors now provide System and Organization Controls (SOC) reports which detail the control environment at the vendor and involve independent third-party testing of those controls that exist at the vendor. SOC reports can provide a useful starting point for evaluating a vendor’s ongoing compliance with the bank’s vendor management policy. However, it is not a substitute for ongoing communication with a vendor.

There is no doubt 2019 was a successful year for banks. But past performance is not a guarantee of future success. Banks face many challenges, risks, and uncertainties, of which only a few have been outlined above. The current landscape may be challenging but it is also filled with opportunity. Banks should consider expanding their services, adopting new technologies, and partnering with other companies to leverage their strengths. Doing so should help position themselves for an exciting decade ahead.

If you have specific concerns about challenges facing your institution, please contact the team. 

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

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.
 

LIBOR is leaving—is your financial institution ready to make the most of it?

In July 2017, the UK’s Financial Conduct Authority announced the phasing out of the London Interbank Offered Rate, commonly known as LIBOR, by the end of 2021¹. With less than two years to go, US federal regulators are urging financial institutions to start assessing their LIBOR exposure and planning their transition. Here we offer some general impacts of the phasing out, some specific actions your institution can take to prepare, and, finally, background on how we got here (see Background at right).

How will the phase-out impact financial institutions?

The Federal Reserve estimates roughly $200 trillion in LIBOR-indexed notional value transactions in the cash and derivatives market². LIBOR is used to help price a variety of financial services products,  including $3.4 trillion in business loans and $1.3 trillion in consumer loans, as well as derivatives, swaps, and other credit instruments. Even excluding loans and financial instruments set to mature before 2021—estimated by the FDIC at 82% of the above $200 trillion—LIBOR exposure is still significant³.

A financial institution’s ability to lend money is largely dependent on the relative stability of its capital position, or lack thereof. For institutions with a significant amount of LIBOR-indexed assets and liabilities, that means less certainty in expected future cash flows and a less stable capital position, which could prompt institutions to deny loans they might otherwise have approved. A change in expected cash flows could also have several indirect consequences. Criticized assets, assessed for impairment based on their expected future cash flows, could require a specific reserve due to lower present value of expected future cash flows.

The importance of fallback language in loan agreements

Fallback language in loan agreements plays a pivotal role in financial institutions’ ability to manage their LIBOR-related financial results. Most loan agreements include language that provides guidance for determining an alternate reference rate to “fall back” on in the event the loan’s original reference rate is discontinued. However, if this language is non-existent, contains fallbacks that are no longer adequate, or lacks certain key provisions, it can create unexpected issues when it comes time for financial institutions to reprice their LIBOR loans. Here are some examples:

• Non-existent or inadequate fallbacks
  According to the Alternative Reference Rates Committee, a group of private-market participants convened by the Federal Reserve to help ensure a successful LIBOR transition, "Most contracts referencing LIBOR do not appear to have envisioned a permanent or indefinite cessation of LIBOR and have fallbacks that would not be economically appropriate"⁴.
  
  For instance, industry regulators have warned that without updated fallback language, the discontinuation of LIBOR could prompt some variable-rate loans to become fixed-rate², causing unanticipated changes in interest rate risk for financial institutions. In a declining rate environment, this may prove beneficial as loans at variable rates become fixed. But in a rising rate environment, the resulting shrink in net interest margins would have a direct and adverse impact on the bottom line.

• No spread adjustment
  Once LIBOR is discontinued, LIBOR-indexed loans will need to be repriced at a new reference rate, which could be well above or below LIBOR. If loan agreements don’t provide for an adjustment of the spread between LIBOR and the new rate, that could prompt unexpected changes in the financial position of both borrowers and lenders³. Take, for instance, a loan made at the Secured Overnight Financing Rate (SOFR), generally considered the likely replacement for USD LIBOR. Since SOFR tends to be lower than three-month LIBOR, a loan agreement using it that does not allow for a spread adjustment would generate lower loan payments for the borrower, which means less interest income for the lender.
  
  Not allowing for a spread adjustment on reference rates lower than LIBOR could also cause a change in expected prepayments—say, for instance, if borrowers with fixed-rate loans decide to refinance at adjustable rates—which would impact post-CECL allowance calculations like the weighted-average remaining maturity (WARM) method, which uses estimated prepayments as an input.

What can your financial institution do to prepare?

The Federal Reserve and the SEC have urged financial institutions to immediately evaluate their LIBOR exposure and expedite their transition. Though the FDIC has expressed no intent to examine financial institutions for the status of LIBOR planning or critique loans based on use of LIBOR³, Federal Reserve supervisory teams have been including LIBOR transitions in their regular monitoring of large financial institutions⁵. The SEC has also encouraged companies to provide investors with robust disclosures regarding their LIBOR transition, which may include a notional value of LIBOR exposure².

Financial institutions should start by analyzing their LIBOR exposure beyond 2021. If you don’t expect significant exposure, further analysis may be unnecessary. However, if you do expect significant future LIBOR exposure, your institution should conduct stress testing using LIBOR as an isolated variable by running hypothetical transition scenarios and assessing the potential financial impact.

Closely examine and assess fallback language in loan agreements. For existing loan agreements, you may need to make amendments, which could require consent from counterparties². For new loan agreements maturing beyond 2021, lenders should consider selecting an alternate reference rate. New contract language for financial instruments and residential mortgages is currently being drafted by the International Securities Dealers Association and the Federal Housing Finance Authority, respectively³—both of which may prove helpful in updating loan agreements.

Lenders should also consider their underwriting policies. Loan underwriters will need to adjust the spread on new loans to accurately reflect the price of risk, because volatility and market tendencies of alternate loan reference rates may not mirror LIBOR’s. What’s more, SOFR lacks abundant historical data for use in analyzing volatility and market tendencies, making accurate loan pricing more difficult.

Conclusion: Start assessing your LIBOR risk soon

The cessation of LIBOR brings challenges and opportunities that will require in-depth analysis and making difficult decisions. Financial institutions and consumers should heed the advice of regulators and start assessing their LIBOR risk now. Those that do will not only be better prepared―but also better positioned―to capitalize on the opportunities it presents.

Need help assessing your LIBOR risk and preparing to transition? Contact BerryDunn’s financial services specialists.

¹ https://www.washingtonpost.com/business/2017/07/27/acdd411c-72bc-11e7-8c17-533c52b2f014_story.html?utm_term=.856137e72385
² Thomson Reuters Checkpoint Newsstand April 10, 2019
³ https://www.fdic.gov/regulations/examinations/supervisory/insights/siwin18/si-winter-2018.pdf
^{4 https://bankingjournal.aba.com/2019/04/libor-transition-panel-recommends-fallback-language-for-key-instruments/
5} https://www.reuters.com/article/us-usa-fed-libor/fed-urges-u-s-financial-industry-to-accelerate-libor-transition-idUSKCN1RM25T

Over the course of its day-to-day operations, every organization acquires, stores, and transmits Protected Health Information (PHI), including names, email addresses, phone numbers, account numbers, and social security numbers.

Yet the security of each organization’s PHI varies dramatically, as does its need for compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Organizations that meet the definition of a covered entity or business associate under HIPAA must comply with requirements to protect the privacy and security of health information.

Noncompliance can have devastating consequences for an organization, including:

• Civil violations, with fines ranging from $100 to $50,000 per violation
• Criminal penalties, with fines ranging from around $50,000 to $250,000, plus imprisonment

All it takes is just one security or privacy breach. As breaches of all kinds continue to rise, this may be the perfect time to evaluate the health of your organization’s HIPAA compliance. To keep in compliance and minimize your risk of a breach, your organization should have:

• An up-to-date and comprehensive HIPAA security and privacy plan
• Comprehensive HIPAA training for employees
• Staff who are aware of all PHI categories
• Sufficiently encrypted devices and strong password policies

HIPAA Health Check: A Thorough Diagnosis

If your organization doesn’t have these safeguards in place, it’s time to start preparing for the worst — and undergo a HIPAA health check.

Organizations need to understand what they have in place, and where they need to bolster their practice. Here are a variety of fact-finding methods and tools we recommend, including (but not limited to):

• Administrative, technical, and physical risk analyses
• Policy, procedure, and business documentation reviews
• Staff surveys and interviews
• IT audits and testing of data security

Once you have diagnosed your organization’s “as-is” status, you need to move your organization toward the “to-be” status — that is, toward HIPAA compliance — by:

• Prioritizing your HIPAA security and privacy risks
• Developing tactics to mitigate those risks
• Providing tools and tactics for security and privacy breach prevention and minimization
• Creating or updating policies, procedures, and business documents, including a HIPAA security and privacy plan

As each organization is different, there are many factors to consider as you go through these processes, and customize your approach to the HIPAA-compliance needs of your organization.

The Road to Wellness

An ounce of prevention is worth a pound of cure. Don’t let a security or privacy breach jump-start the compliance process. Reach out to us for a HIPAA health check. Contact us if you have any questions on how to get your organization on the road to wellness.

Is your organization a service provider that hosts or supports sensitive customer data, (e.g., personal health information (PHI), personally identifiable information (PII))? If so, you need to be aware of a recent decision by the American Institute of Certified Public Accountants that may affect how your organization manages its systems and data.

In April, the AICPA’s Assurance Executive Committee decided to replace the five Trust Service Principles (TSPs) with Trust Services Criteria (TSC), requiring service organizations to completely rework their internal controls, and present SOC 2 findings in a revised format. This switch may sound frustrating or intimidating, but we can help you understand the difference between the principles and the criteria.

The SOC 2 Today
Service providers design and implement internal controls to protect customer data and comply with certain regulations. Typically, a service provider hires an independent auditor to conduct an annual Service Organization Control (SOC) 2 examination to help ensure that controls work as intended. Among other things, the resulting SOC 2 report assures stakeholders (customers and business partners) the organization is reducing data risk and exposure.

Currently, SOC 2 reports focus on five Trust Services Principles (TSP):

• Security: Information and systems are protected against unauthorized access, unauthorized disclosure of information, and damage to systems that can compromise the availability, integrity, confidentiality, and privacy of information or systems — and affect the entity's ability to meet its objectives.

• Availability: Information and systems are available for operation and use to meet the entity's objectives.

• Processing Integrity: System processing is complete, valid, accurate, timely, and authorized to meet the entity's objectives.

• Confidentiality: Information designated as confidential is protected to meet the entity's objectives.

• Privacy: Personal information is collected, used, retained, disclosed, and disposed of to meet the entity's objectives.

New SOC 2 Format
The TSC directly relate to the 17 principles found in the Committee of Sponsoring Organization (COSO)’s 2013 Framework for evaluating internal controls, and include additional criteria related to COSO Principle 12. The new TSC are:

• Control Environment: emphasis on ethical values, board oversight, authority and responsibilities, workforce competence, and accountability.

• Risk Assessment: emphasis on the risk assessment process, how to identify and analyze risks, fraud-related risks, and how changes in risk impact internal controls.

• Control Activities: Emphasis on how you develop controls to mitigate risk, how you develop technology controls, and how you deploy controls to an organization through the use of policies and procedures.

• Information and Communication: Emphasis on how you communicate internal of the organization to internal and external parties.

• Monitoring: Emphasis on how you evaluate internal controls and how you communicate and address any control deficiencies.

The AICPA has provided nearly 300 Points of Focus (POF), supporting controls that organizations should consider when addressing the TSC. The POF offer guidance and considerations for controls that address the specifics of the TSC, but they are not required.

Points of Focus
Organizations now have some work to do to meet the guidelines. The good news: there’s still plenty of time to make necessary changes. You can use the current TSP format before December 15, 2018. Any SOC 2 report presented after December 15, 2018, must incorporate the new TSC format. The AICPA has provided a mapping spreadsheet to help service organizations move from TSP to the TSC format.

Contact Chris Ellingwood to learn more about how we can help you gain control of your SOC 2 reporting efforts.