Ask an administrator whether the organization has IT policies and the answer is often a vague yes. Somewhere there is a handbook page about computers, and perhaps a signed form from years ago. When a surveyor, an auditor, an insurer or an attorney asks for them, the scramble begins.
A small, well-organized policy library solves this. It does not need to be long or written in legal prose. It needs to be accurate, findable, understood by staff and reviewed on a schedule. Here are the policies most healthcare and senior-living organizations should maintain, and how to keep them alive.
Regulation. The HIPAA Security Rule expects written policies and procedures, and documentation of them, for safeguarding electronic protected health information.
Insurance. Cyber insurance applications ask whether specific policies exist.
Consistency. Staff need clear answers about what is allowed.
Accountability. When someone breaks a rule, a written and acknowledged policy makes consequences fair.
Onboarding. New hires should learn expectations on day one.
This explains what staff may and may not do with organizational systems. Cover personal use limits, prohibited activities, expectations for internet and email use, and the fact that systems may be monitored. Keep it short and readable.
Address how staff handle email and messaging:
Sending protected health information only through approved, secure methods
Recognizing and reporting phishing
Rules on auto-forwarding to personal accounts
Use of text messaging and consumer chat apps for resident information
Retention expectations
Describe standards for computers, tablets and phones:
Screen locks and automatic sign-out
Disk encryption requirements
Where devices may be placed, such as screens facing away from public areas
Rules for removable media
Reporting lost or stolen devices immediately
If staff use personal phones for work email or messaging, set conditions: required passcodes, ability to remotely wipe organizational data, and what happens when someone leaves.
State requirements for strong, unique passwords, multi-factor authentication, no sharing of credentials and role-based access. Include onboarding, transfer and termination steps, so access is granted and removed promptly.
Spell out who may work remotely, from which devices and over which secured connections.
Define what counts as sensitive, where it may be stored, how it may be shared, and how it is disposed of. Include rules for paper printouts and exports.
Document what is backed up, how often, how long it is kept, how restoration is tested and who is responsible.
Explain how staff report suspected incidents, who responds, and what the escalation steps are. Make the first step simple: tell someone immediately. Include breach assessment and notification procedures.
Describe how new vendors are vetted, when business associate agreements are required, and how access is limited and reviewed.
Define how new software is requested, approved and installed, and how significant changes are tested and documented.
Cover downtime procedures, communication during outages and restoration priorities. Align with your emergency preparedness plan.
Write in plain English. If a CNA cannot understand it, rewrite it.
Keep each policy to a page or two where possible, with procedures in separate documents.
Use a consistent template with purpose, scope, policy statements, responsibilities, owner, effective date and review date.
Store them in one place that staff can reach easily.
Name an owner for each policy.
Have new employees review key policies and sign an acknowledgment during onboarding. Repeat annually, along with security awareness training. Retain records of who acknowledged which version.
Review each policy at least annually, and after any significant incident, regulatory change or technology shift. Record the review date and any changes, even when no changes are needed. Retain prior versions as required by your documentation policies.
Policies that are never enforced teach staff they do not matter. Apply consequences consistently, and focus first on coaching for honest mistakes.
If you have nothing, begin with acceptable use, email, device security and incident reporting. Add others over a few months. An imperfect policy in use beats a perfect one in a drawer.
UnityCare IT helps healthcare organizations draft, organize and review IT policies suited to their size, and ensures procedures match what the technology actually does.
An outsourced IT department with proactive maintenance and one number to call.
Call or text: 405-285-3845
New customers: start@unitycareit.com
Existing customers: support@unitycareit.com
Address: UnityCare Technologies, 2524 N Broadway Ste 554, PMB 947974, Edmond, Oklahoma 73034-4172