1. Purpose

This document defines the procedures for identifying, containing, and responding to security incidents involving Protected Health Information (PHI) within M4NG0 OS deployments. It establishes timelines, responsibilities, and escalation paths aligned with HIPAA Breach Notification Rule requirements.

2. Incident Classification

Level	Description	Example
Critical	Confirmed unauthorized access to PHI	Database exfiltration, unauthorized data export
High	Suspected unauthorized access attempt	Repeated failed logins, privilege escalation attempt
Medium	Policy violation without data exposure	Staff accessing records outside their role
Low	Security configuration issue	Expired certificate, missed backup cycle

3. Response Phases

Phase 1: Detection & Containment (0–2 hours)

Incident detected via audit log anomalies, staff report, or system alerts.
Affected system component isolated immediately.
Compromised user accounts suspended.
Audit logs preserved and protected from modification.
Internal incident team notified.

Phase 2: Assessment (2–24 hours)

Determine scope: which records, which patients, which time period.
Review audit logs for access patterns leading to the incident.
Determine whether PHI was actually accessed, acquired, or disclosed.
Assess whether the incident constitutes a breach under HIPAA.
Document findings in incident report.

Phase 3: Notification (24–48 hours)

Hospital administration notified within 48 hours of confirmed breach.
Notification includes: nature of the breach, PHI involved, individuals affected, mitigation steps taken, recommended protective actions.
Hospital is responsible for notifying affected individuals and HHS as required by HIPAA (within 60 days for breaches affecting 500+ individuals).
M4NG0 provides technical support for the hospital's notification process.

Phase 4: Remediation (48 hours – 2 weeks)

Root cause analysis completed.
Security patch deployed if software vulnerability identified.
Access controls reviewed and tightened.
Staff retraining conducted if human error involved.
System monitoring increased for 30 days post-incident.

Phase 5: Post-Incident Review (2–4 weeks)

Final incident report delivered to hospital administration.
Lessons learned documented and incorporated into security procedures.
Policy updates implemented if gaps identified.
Audit log retention verified for compliance period (6+ years).

4. Architectural Safeguards

M4NG0 OS includes design-level protections that reduce breach risk:

On-premise deployment: PHI is not transmitted over public internet during normal operations.
Field-level encryption: Even if database files are accessed, PHI fields remain encrypted.
Hash-chained audit logs: Tamper detection is built into the logging architecture. Any modification to historical logs is detectable.
Zero vendor access: M4NG0 cannot remotely access the hospital's deployment or data.

This plan is provided as a framework. Specific procedures are customized during deployment based on the hospital's existing incident response policies. Contact sales@m4ng0.com for details.

Breach Response Plan