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QualityNet Security

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Security Policy


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Awareness & Training


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Security Point Of Contact


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Incident Response





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Introduction

During onboarding, and before accessing any QualitNet system or application, each user must sign Rules of Behavior, complete the appropriate training, and provide evidence of training completion to their

HCQIS Security Awareness Training (SAT) & Certification Administration Instructions :  HHS and CMS in accordance to Federal Information Security Management Act (FISMA) of 2002 and other policies requires that all Federal CMS and Contractor users of Federal Information Systems to be exposed to security and privacy awareness training materials at least annually. This is to inform federal employees, contractors and other users of information systems that support the operations and assets of the agency, of:

  • Information Security risks associated with technologies and their activities while utilizing those technologies.

  • Responsibilities in complying with agency policies and procedures designed to reduce risks.

  • Overview of protecting Personally Identifying Information (PII) or Personal Health Information (PHI) of any individual as directed in the Privacy Act of 1974.

  • Records Management and Retention.

During onboarding and before access to any HCQIS system or application each user must complete proper training requirements on an annual basis and must provide evidence of completion to his/her respective Security Point of Contact (SPOC) who ; the SPOC will track all required training within the organizationtheir organization. In many cases, an annual attestation is also provided to the organization’s CMS Contracting Officer’s Representative (COR) as a deliverable.  

If you have questions about policy or need more information regarding contract requirements, please contact your COR.



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Required Training



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Record Keeping for SPOCs



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Security Awareness Training (SAT) - The QualityNet program

During onboarding and before access to any HCQIS system or application each user must complete proper training requirements on an annual basis and must provide evidence of completion to his/her respective Security Point of Contact (SPOC) who will track all required training within the organization.

Note: In most cases, an annual attestation is also provided to the CMS COR as a deliverable. Contact your COR for specific contract deliverables and dates.

Security Awareness Training

The HCQIS system

utilizes the DoD Cyber Exchange

(h ttps://public.cyber.mil/cyber-training/)

, a publicly accessible training library with course offerings, to allow

Contractors

contractors to meet part of the CMS SAT requirements.

These trainings include the C yber Awareness Challenge and 

SAT Training is broken into two (2) separate trainings:  

Identifying and Safeguarding Personable Privacy Training.

Records Management

The Department of Health and Human Services (HHS) Records Management training Training - Additional to Security Awareness training, the HHS Records Management Training is a mandatory training requirement and is outlined in   the HHS Policy for Records Management  and the Office of Management and Budget (OMB) and /National Archives and Records Administration (NARA) joint Directive   M-19-21, Transition to Electronic Records.  The purpose of this records management training is to provide an overview of employee user responsibilities for records managementhandling, help employees users tell the difference between records and non-records, and assist employees in them in learning how to manage the federal records lifecycle.  

Note: HHS The HHS Office of Human Capital manages Records Management records management training and requirements for CMS. Therefore, separate or updated instructions may be sent issued by HHS which to include updates to new training linksrequirements, requirements or content and should be used as underlining guidance outside of these instructionscontent or links. Please check with your COR on for any changes to these requirementsthe information provided by HHS.Below are the links to the websites where the three required trainings are hosted. DoD provides the links for the security trainings and are subject to change at any time. If a link is broken, you may also do a web search for the name of the training and use the appropriate search result since they are publicly available.


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Step 1 - Complete the required online training by selecting the corresponding modules listed below.

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Step 2 - Enter

  • Complete the online trainings as defined by the deliverable, contract onboarding period or other timeframe identified by the program/contract.
    • Type

    your name in the Certification of Completion’s online display

    for the Certificate of Completion

    , which is provided at the successful conclusion of the training

    and print a copy.
    1. Note: Screen captures Training certificate are acceptable if no printable certificate exists or if any errors occur while printing.

    .

    Step 3 - Take a screen capture (shot) or save a copy of the certificate locally then provide a copy of your completed certification to your organization’s assigned

    Sign the Certificate of Completion and provide the original to the local

    Security Point of Contact (SPOC) who will maintain a copy for record retention.


    Recently transitioned from a previous contract?

    New users take training during onboarding and before initial access then annually thereafter. Some contracts and organizations require all users to complete training by a specific time each year. There also may be times where a user has transferred from another contract and has taken required training.  Therefore, if a user has started or transferred from a previous QualityNet contract and has taken all required trainings within the last 90 days, that user is except from taking any training again until the following calendar year or deliverable period; whichever schedule is followed. Please contact your COR for any questions regarding requirements. 


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    The SPOC should adhere to the following guidelines related to certification and attestation of training results:

    1. Only one
    Only (1)
    1. memo is required for all sites under each prime contract region/area/site.
    2. The Certification Memo must be signed
    by the Security Point of Contact (SPOC)/ Security Officer (SO) and the organization's
    1. (digitally if preferred) by any designated SPOC and the organization’s designated Program Lead. 
    2. You may apply a naming convention that best suits your organization, Contract or deliverable
    . Some examples of the document format names are listed below:
    1. Naming format for BFCC: "BFCC-QIO-(Contract Name)_SAT_20xx.pdf"
    2. Naming format for QIN: "QIN-QIO-(Contract Name)_SAT_20xx.pdf"
    3. Other Organizations: "(Org/Contract Name)_SAT_20xx.pdf"
  • You may also have multiple sites that need to be tracked separately. "Site Identification" located at the top of the Certification Memo will help (if applicable):
    1. Region/Area/Network ID; this will vary between contract type/organization.
      1. "BFCC-QIO Region 1"
      2. "QIN-QIO Area-G"
    1. , but that is easy to understand by other readers.
    2. Submit the completed certification memo electronically to
    your
    1. you’re COR using the specified vehicle outlined in the contract
    (email, CDS, DARRT, etc.)
    1. as directed by the CMS COR
    (if applicable).
    1. .


    Organizational SPOCs may leverage the provided template to fulfill the requirement. 

    QNet Security Awareness Certification Template.docx


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    Records must be updated and maintained at all times, but they are only to be submitted to CMS if

    SAT Records are not required for submission unless

    requested by the COR or the Information Systems Security Officer (ISSO

    . SAT Records must always be updated and maintained. (SAT record

    ). Record templates are available within

    HCQIS

    the Security

    Resources on QNP

    page on the QualityNet Communications Hub or may be obtained

    by the

    through your CMS COR

    /ISSO

    .

    Contracts

    acting under

    operating across multiple sites (prime/sub) may exercise the option of having multiple

    SAT

    records or a single

    SAT

    record that reflects

    ALL

    all individual sites and each user

    respectfully

    respectively.

    At the top of each page insert the Contract name and specify the site if applicable.

    For multiple sites in a single area, you may use a different table that identifies each

    state

    State/region for each site.

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    Organizational SPOCs may leverage the provided template to fulfill the requirement. 

    Security Awareness Training Record template



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    Newly on-boarded HCQIS Services users who have taken all three training modules within the last 90 days of the organization's certification period are EXEMPT from taking SAT training for the current annual certification period. This group of users will take security awareness training as normal during the following annual certification period.

    Note: Any deviations from either training module will require the user to take any missed training during the current certification period.
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