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Requirement 12: Support Information Security with Organizational Policies and Programs

PCI Security Standards Council

In the last post, we discussed the requirements and best practices to test security of systems and networks regularly. In this post, we will understand PCI DSS Requirement #12 Support Information Security with Organizational Policies and Programs.

Overview

The organization’s overall information security policy sets the tone for the whole entity and informs personnel what is expected of them. All personnel should be aware of the sensitivity of cardholder data and their responsibilities for protecting it. For the purposes, “personnel” refers to full-time and part-time employees, temporary employees, contractors, and consultants with security responsibilities for protecting account data or that can impact the security of account data.

12.1 A comprehensive information security policy that governs and provides direction for protection of the entity’s information assets is known and current

12.1.1 An overall information security policy is: • Established • Published • Maintained • Disseminated to all relevant personnel, as well as to relevant vendors and business partners

The security policy for the organization identifies the purpose, scope, accountability, and information that clearly defines the organization’s position regarding information security.

The overall information security policy differs from individual security policies that address specific technology or security disciplines. This policy sets forth the directives for the entire organization whereas individual security policies align and support the overall security policy and communicate specific objectives for technology or security disciplines.

It is important that all relevant personnel within the organization, as well as relevant third parties, vendors, and business partners are aware of the organization’s information security policy and their responsibilities for protecting information assets.

12.1.2 The information security policy is: • Reviewed at least once every 12 months • Updated as needed to reflect changes to business objectives or risks to the environment

Security threats and associated protection methods evolve rapidly. Without updating the information security policy to reflect relevant changes, new measures to defend against these threats may not be addressed.

12.1.3 The security policy clearly defines information security roles and responsibilities for all personnel, and all personnel are aware of and acknowledge their information security responsibilities

Without clearly defined security roles and responsibilities assigned, there could be misuse of the organization’s information assets or inconsistent interaction with information security personnel, leading to insecure implementation of technologies or use of outdated or insecure technologies.

12.1.4 Responsibility for information security is formally assigned to a Chief Information Security Officer or other information security knowledgeable member of executive management

Entities should also consider transition and/or succession plans for these key personnel to avoid potential gaps in critical security activities.

12.2 Acceptable use policies for end-user technologies are defined and implemented

12.2.1 Acceptable use policies for end-user technologies are documented and implemented, including: • Explicit approval by authorized parties • Acceptable uses of the technology • List of products approved by the company for employee use, including hardware and software

It is important that usage policies are supported by technical controls to manage the enforcement of the policies.

Structuring polices as simple “do” and “do not” requirements that are linked to a purpose can help remove ambiguity and provide personnel with the context for the requirement.

12.3 Risks to the cardholder data environment are formally identified, evaluated, and managed

12.3.1 Each PCI DSS requirement that provides flexibility for how frequently it is performed (for example, requirements to be performed periodically) is supported by a targeted risk analysis that is documented and includes: • Identification of the assets being protected • Identification of the threat(s) that the requirement is protecting against • Identification of factors that contribute to the likelihood and/or impact of a threat being realized • Resulting analysis that determines, and includes justification for, how frequently the requirement must be performed to minimize the likelihood of the threat being realized • Review of each targeted risk analysis at least once every 12 months to determine whether the results are still valid or if an updated risk analysis is needed • Performance of updated risk analyses when needed, as determined by the annual review

An enterprise-wide risk assessment, which is a point-in-time activity that enables entities to identify threats and associated vulnerabilities, is recommended, but is not required, for entities to determine and understand broader and emerging threats with the potential to negatively impact its business. This enterprise-wide risk assessment could be established as part of an overarching risk management program that is used as an input to the annual review of an organization’s overall information security policy.

Examples of risk-assessment methodologies for enterprise-wide risk assessments include, but are not limited to, ISO 27005 and NIST SP 800-30.

12.3.2 A targeted risk analysis is performed for each PCI DSS requirement that the entity meets with the customized approach, to include: • Documented evidence detailing each element specified in Appendix D: Customized Approach (including, at a minimum, a controls matrix and risk analysis) • Approval of documented evidence by senior management • Performance of the targeted analysis of risk at least once every 12 months

A risk analysis following a repeatable and robust methodology enables an entity to meet the customized approach objective.

12.3.3 Cryptographic cipher suites and protocols in use are documented and reviewed at least once every 12 months, including at least the following: • An up-to-date inventory of all cryptographic cipher suites and protocols in use, including purpose and where used • Active monitoring of industry trends regarding continued viability of all cryptographic cipher suites and protocols in use • A documented strategy to respond to anticipated changes in cryptographic vulnerabilities

Cryptographic agility is important to ensure an alternative to the original encryption method or cryptographic primitive is available, with plans to upgrade to the alternative without significant change to system infrastructure. For example, if the entity is aware of when protocols or algorithms will be deprecated by standards bodies, it can make proactive plans to upgrade before the deprecation is impactful to operations.

12.3.4 Hardware and software technologies in use are reviewed at least once every 12 months, including at least the following: • Analysis that the technologies continue to receive security fixes from vendors promptly • Analysis that the technologies continue to support (and do not preclude) the entity’s PCI DSS compliance • Documentation of any industry announcements or trends related to a technology, such as when a vendor has announced “end of life” plans for a technology • Documentation of a plan, approved by senior management, to remediate outdated technologies, including those for which vendors have announced “end of life” plans

Organizations should review firmware versions to ensure they remain current and supported by the vendors. Organizations also need to be aware of changes made by technology vendors to their products or processes to understand how such changes may impact the organization’s use of the technology.

Regular reviews of technologies that impact or influence PCI DSS controls can assist with purchasing, usage, and deployment strategies, and ensure controls that rely on those technologies remain effective. These reviews include, but are not limited to, reviewing technologies that are no longer supported by the vendor and/or no longer meet the security needs of the organization.

12.4 PCI DSS compliance is managed

12.4.1 Additional requirement for service providers only: Responsibility is established by executive management for the protection of cardholder data and a PCI DSS compliance program to include: • Overall accountability for maintaining PCI DSS compliance • Defining a charter for a PCI DSS compliance program and communication to executive management

Executive management assignment of PCI DSS compliance responsibilities ensures executive-level visibility into the PCI DSS compliance program and allows for the opportunity to ask appropriate questions to determine the effectiveness of the program and influence strategic priorities.

12.4.2 Additional requirement for service providers only: Reviews are performed at least once every three months to confirm that personnel are performing their tasks in accordance with all security policies and operational procedures. Reviews are performed by personnel other than those responsible for performing the given task and include, but are not limited to, the following tasks: • Daily log reviews • Configuration reviews for network security controls • Applying configuration standards to new systems • Responding to security alerts • Change-management processes

These reviews can also be used to verify that appropriate evidence is being maintained for example, audit logs, vulnerability scan reports, reviews of network security control rulesets to assist in the entity’s preparation for its next PCI DSS assessment.

12.4.2.1 Additional requirement for service providers only: Reviews conducted are documented to include: • Results of the reviews • Documented remediation actions taken for any tasks that were found to not be performed • Review and sign-off of results by personnel assigned responsibility for the PCI DSS compliance program

The intent of these independent checks is to confirm whether security activities are being performed on an ongoing basis. These reviews can also be used to verify that appropriate evidence is being maintained for example, audit logs, vulnerability scan reports, reviews of network security control rulesets to assist in the entity’s preparation for its next PCI DSS assessment.

12.5 PCI DSS scope is documented and validated

12.5.1 An inventory of system components that are in scope for PCI DSS, including a description of function/use, is maintained and kept current

If an entity keeps an inventory of all assets, those system components in scope for PCI DSS should be clearly identifiable among the other assets.

Inventories should include containers or images that may be instantiated.

Assigning an owner to the inventory helps to ensure the inventory stays current.

12.5.2 PCI DSS scope is documented and confirmed by the entity at least once every 12 months and upon significant change to the in-scope environment. At a minimum, the scoping validation includes: • Identifying all data flows for the various payment stages (for example, authorization, capture settlement, chargebacks, and refunds) and acceptance channels (for example, card-present, card-not-present, and e-commerce) • Updating all data-flow diagrams • Identifying all locations where account data is stored, processed, and transmitted, including but not limited to: 1) any locations outside of the currently defined CDE, 2) applications that process CHD, 3) transmissions between systems and networks, and 4) file backups • Identifying all system components in the CDE, connected to the CDE, or that could impact security of the CDE • Identifying all segmentation controls in use and the environment(s) from which the CDE is segmented, including justification for environments being out of scope • Identifying all connections from third-party entities with access to the CDE • Confirming that all identified data flows, account data, system components, segmentation controls, and connections from third parties with access to the CDE are included in scope

Accurate scoping involves critically evaluating the CDE and all connected system components to determine the necessary coverage for PCI DSS requirements. Scoping activities, including careful analysis and ongoing monitoring, help to ensure that in-scope systems are appropriately secured. When documenting account data locations, the entity can consider creating a table or spreadsheet that includes the following information: • Data stores (databases, files, cloud, etc.), including the purpose of data storage and the retention period, • Which CHD elements are stored (PAN, expiry date, cardholder name, and/or any elements of SAD prior to completion of authorization), • How data is secured (type of encryption and strength, hashing algorithm and strength, truncation, tokenization), • How access to data stores is logged, including a description of logging mechanism(s) in use (enterprise solution, application level, operating system level, etc.).

In addition to internal systems and networks, all connections from third-party entities for example, business partners, entities providing remote support services, and other service providers need to be identified to determine inclusion for PCI DSS scope. Once the in-scope connections have been identified, the applicable PCI DSS controls can be implemented to reduce the risk of a third-party connection being used to compromise an entity’s CDE.

A data discovery tool or methodology can be used to facilitate identifying all sources and locations of PAN, and to look for PAN that resides on systems and networks outside the currently defined CDE or in unexpected places within the defined CDE for example, in an error log or memory dump file. This approach can help ensure that previously unknown locations of PAN are detected and that the PAN is either eliminated or properly secured.

12.5.2.1 Additional requirement for service providers only: PCI DSS scope is documented and confirmed by the entity at least once every six months and upon significant change to the in-scope environment. At a minimum, the scoping validation

Service providers typically have access to greater volumes of cardholder data than do merchants, or can provide an entry point that can be exploited to then compromise multiple other entities. Service providers also typically have larger and more complex networks that are subject to more frequent change. The probability of overlooked changes to scope in complex and dynamic networks is greater in service providers’ environments.

Validating PCI DSS scope more frequently is likely to discover such overlooked changes before they can be exploited by an attacker.

12.5.3 Additional requirement for service providers only: Significant changes to organizational structure result in a documented (internal) review of the impact to PCI DSS scope and applicability of controls, with results communicated to executive management

An organization’s structure and management define the requirements and protocol for effective and secure operations. Changes to this structure could have negative effects to existing controls and frameworks by reallocating or removing resources that once supported PCI DSS controls or inheriting new responsibilities that may not have established controls in place. Therefore, it is important to revisit PCI DSS scope and controls when there are changes to an organization’s structure and management to ensure controls are in place and active.

12.6 Security awareness education is an ongoing activity

12.6.1 A formal security awareness program is implemented to make all personnel aware of the entity’s information security policy and procedures, and their role in protecting the cardholder data

If personnel are not educated about their company’s information security policies and procedures and their own security responsibilities, security safeguards and processes that have been implemented may become ineffective through unintentional errors or intentional actions.

12.6.2 The security awareness program is: • Reviewed at least once every 12 months, and • Updated as needed to address any new threats and vulnerabilities that may impact the security of the entity’s CDE, or the information provided to personnel about their role in protecting cardholder data

The threat environment and an entity’s defenses are not static. As such, the security awareness program materials must be updated as frequently as needed to ensure that the education received by personnel is up to date and represents the current threat environment.

12.6.3 Personnel receive security awareness training as follows: • Upon hire and at least once every 12 months • Multiple methods of communication are used • Personnel acknowledge at least once every 12 months that they have read and understood the information security policy and procedures

Entities may incorporate new-hire training as part of the Human Resources onboarding process. Training should outline the security-related “dos” and “don’ts.” Periodic refresher training reinforces key security processes and procedures that may be forgotten or bypassed.

Entities should consider requiring security awareness training anytime personnel transfer into roles where they can impact the security of account data from roles where they did not have this impact.

Methods and training content can vary, depending on personnel roles.

12.6.3.1 Security awareness training includes awareness of threats and vulnerabilities that could impact the security of the CDE, including but not limited to: • Phishing and related attacks • Social engineering

An effective security awareness program should include examples of phishing emails and periodic testing to determine the prevalence of personnel reporting such attacks. Training material an entity can consider for this topic include:

  • How to identify phishing and other social engineering attacks.
  • How to react to suspected phishing and social engineering.
  • Where and how to report suspected phishing and social engineering activity.

An emphasis on reporting allows the organization to reward positive behavior, to optimize technical defenses, and to take immediate action to remove similar phishing emails that evaded technical defenses from recipient inboxes.

12.6.3.2 Security awareness training includes awareness about the acceptable use of end-user technologies

By including the key points of the acceptable use policy in regular training and the related context, personnel will understand their responsibilities and how these impact the security of an organization’s systems.

12.7 Personnel are screened to reduce risks from insider threats

12.7.1 Potential personnel who will have access to the CDE are screened, within the constraints of local laws, prior to hire to minimize the risk of attacks from internal sources

Entities should consider screening for existing personnel anytime they transfer into roles where they have access to the CDE from roles where they did not have this access.

To be effective, the level of screening should be appropriate for the position. For example, positions requiring greater responsibility or that have administrative access to critical data or systems may warrant more detailed or more frequent screening than positions with less responsibility and access.

12.8 Risk to information assets associated with third-party service provider (TPSP) relationships is managed

12.8.1 A list of all third-party service providers (TPSPs) with which account data is shared or that could affect the security of account data is maintained, including a description for each of the services provided

Maintaining a list of all TPSPs identifies where potential risk extends outside the organization and defines the organization’s extended attack surface.

12.8.2 Written agreements with TPSPs are maintained as follows: • Written agreements are maintained with all TPSPs with which account data is shared or that could affect the security of the CDE • Written agreements include acknowledgments from TPSPs that they are responsible for the security of account data the TPSPs possess or otherwise store, process, or transmit on behalf of the entity, or to the extent that they could impact the security of the entity’s CDE

The entity may also want to consider including in their written agreement with a TPSP that the TPSP will support the entity’s request for information. Entities will also want to understand whether any TPSPs have “nested” relationships with other TPSPs, meaning the primary TPSP contracts with another TPSP(s) for the purposes of providing a service.

It is important to understand whether the primary TPSP is relying on the secondary TPSP(s) to achieve overall compliance of a service, and what types of written agreements the primary TPSP has in place with the secondary TPSPs. Entities can consider including coverage in their written agreement for any “nested” TPSPs a primary TPSP may use.

12.8.3 An established process is implemented for engaging TPSPs, including proper due diligence prior to engagement

Specific due-diligence processes and goals will vary for each organization. Elements that should be considered include the provider’s reporting practices, breach-notification and incident response procedures, details of how PCI DSS responsibilities are assigned between each party, how the TPSP validates their PCI DSS compliance and what evidence they provide.

12.8.4 A program is implemented to monitor TPSPs’ PCI DSS compliance status at least once every 12 months

If the TPSP offers a variety of services, the compliance status the entity monitors should be specific to those services delivered to the entity and those services in scope for the entity’s PCI DSS assessment.

If a TPSP has a PCI DSS Attestation of Compliance (AOC), the expectation is that the TPSP should provide that to customers upon request to demonstrate their PCI DSS compliance status.

If the TPSP did not undergo a PCI DSS assessment, it may be able to provide other sufficient evidence to demonstrate that it has met the applicable requirements without undergoing a formal compliance validation. For example, the TPSP can provide specific evidence to the entity’s assessor so the assessor can confirm applicable requirements are met. Alternatively, the TPSP can elect to undergo multiple on-demand assessments by each of its customers’ assessors, with each assessment targeted to confirm that applicable requirements are met.

12.8.5 Information is maintained about which PCI DSS requirements are managed by each TPSP, which are managed by the entity, and any that are shared between the TPSP and the entity

Entities can document these responsibilities via a matrix that identifies all applicable PCI DSS requirements and indicates for each requirement whether the entity or TPSP is responsible for meeting that requirement or whether it is a shared responsibility. This type of document is often referred to as a responsibility matrix.

It is also important for entities to understand whether any TPSPs have “nested” relationships with other TPSPs, meaning the primary TPSP contracts with another TPSP(s) for the purposes of providing a service. It is important to understand whether the primary TPSP is relying on the secondary TPSP(s) to achieve overall compliance of a service, and how the primary TPSP is monitoring performance of the service and the PCI DSS compliance status of the secondary TPSP(s). Note that it is the responsibility of the primary TPSP to manage and monitor any secondary TPSPs.

12.9 Third-party service providers (TPSPs) support their customers’ PCI DSS compliance

12.9.1 Additional requirement for service providers only: TPSPs acknowledge in writing to customers that they are responsible for the security of account data the TPSP possesses or otherwise stores, processes, or transmits on behalf of the customer, or to the extent that they could impact the security of the customer’s CDE

This requirement is intended to promote a consistent level of understanding between TPSPs and their customers about their applicable PCI DSS responsibilities. The acknowledgment of the TPSPs evidences their commitment to maintaining proper security of account data that it obtains from its clients.

The method by which the TPSP provides written acknowledgment should be agreed between the provider and its customers.

12.9.2 Additional requirement for service providers only: TPSPs support their customers’ requests for information and by providing the following upon customer request: • PCI DSS compliance status information for any service the TPSP performs on behalf of customers • Information about which PCI DSS requirements are the responsibility of the TPSP and which are the responsibility of the customer, including any shared responsibilities

If a TPSP has a PCI DSS Attestation of Compliance (AOC), the expectation is that the TPSP should provide that to customers upon request to demonstrate their PCI DSS compliance status. If the TPSP did not undergo a PCI DSS assessment, they may be able to provide other sufficient evidence to demonstrate that it has met the applicable requirements without undergoing a formal compliance validation. For example, the TPSP can provide specific evidence to the entity’s assessor so the assessor can confirm applicable requirements are met. Alternatively, the TPSP can elect to undergo multiple on-demand assessments by each of its customers’ assessors, with each assessment targeted to confirm that applicable requirements are met.

TPSPs should provide sufficient evidence to their customers to verify that the scope of the TPSP’s PCI DSS assessment covered the services applicable to the customer and that the relevant PCI DSS requirements were examined and determined to be in place.

TPSPs may define their PCI DSS responsibilities to be the same for all their customers; otherwise, this responsibility should be agreed upon by both the customer and TPSP. It is important that the customer understands which PCI DSS requirements and sub-requirements its TPSPs have agreed to meet, which requirements are shared between the TPSP and the customer, and for those that are shared, specifics about how the requirements are shared and which entity is responsible for meeting each sub-requirement. An example of a way to document these responsibilities is via a matrix that identifies all applicable PCI DSS requirements and indicates whether the customer or TPSP is responsible for meeting that requirement or whether it is a shared responsibility.

12.10 Suspected and confirmed security incidents that could impact the CDE are responded to immediately

12.10.1 An incident response plan exists and is ready to be activated in the event of a suspected or confirmed security incident. The plan includes, but is not limited to: • Roles, responsibilities, and communication and contact strategies in the event of a suspected or confirmed security incident, including notification of payment brands and acquirers, at a minimum • Incident response procedures with specific containment and mitigation activities for different types of incidents • Business recovery and continuity procedures • Data backup processes • Analysis of legal requirements for reporting compromises • Coverage and responses of all critical system components • Reference or inclusion of incident response procedures from the payment brands

The incident response plan should be thorough and contain all the key elements for stakeholders (for example, legal, communications) to allow the entity to respond effectively in the event of a breach that could impact account data. It is important to keep the plan up to date with current contact information of all individuals designated as having a role in incident response. Other relevant parties for notifications may include customers, financial institutions (acquirers and issuers), and business partners.

Entities should consider how to address all compromises of data within the CDE in their incident response plans, including to account data, wireless encryption keys, encryption keys used for transmission and storage or account data or cardholder data, etc.

12.10.2 At least once every 12 months, the security incident response plan is: • Reviewed and the content is updated as needed • Tested

The test of the incident response plan can include simulated incidents and the corresponding responses in the form of a “table-top exercise”, that include participation by relevant personnel. A review of the incident and the quality of the response can provide entities with the assurance that all required elements are included in the plan.

12.10.3 Specific personnel are designated to be available on a 24/7 basis to respond to suspected or confirmed security incidents

Often, specific personnel are designated to be part of a security incident response team, with the team having overall responsibility for responding to incidents (perhaps on a rotating schedule basis) and managing those incidents in accordance with the plan. The incident response team can consist of core members who are permanently assigned or “on-demand” personnel who may be called up as necessary, depending on their expertise and the specifics of the incident.

Having available resources to respond quickly to incidents minimizes disruption to the organization.

Examples of types of activity the team or individuals should respond to include any evidence of unauthorized activity, detection of unauthorized wireless access points, critical IDS alerts, and reports of unauthorized critical system or content file changes.

12.10.4 Personnel responsible for responding to suspected and confirmed security incidents are appropriately and periodically trained on their incident response responsibilities

It is important that all personnel involved in incident response are trained and knowledgeable about managing evidence for forensics and investigations.

12.10.4.1 The frequency of periodic training for incident response personnel is defined in the entity’s targeted risk analysis

Each entity’s environment and incident response plan are different and the approach will depend on a number of factors, including the size and complexity of the entity, the degree of change in the environment, the size of the incident response team, and the turnover in personnel.

Performing a risk analysis will allow the entity to determine the optimum frequency for training personnel with incident response responsibilities.

12.10.5 The security incident response plan includes monitoring and responding to alerts from security monitoring systems, including but not limited to: • Intrusion-detection and intrusion-prevention systems • Network security controls • Change-detection mechanisms for critical files • The change-and tamper-detection mechanism for payment pages • Detection of unauthorized wireless access points

Responding to alerts generated by security monitoring systems that are explicitly designed to focus on potential risk to data is critical to prevent a breach and therefore, this must be included in the incident-response processes.

12.10.6 The security incident response plan is modified and evolved according to lessons learned and to incorporate industry developments

The lessons-learned exercise should include all levels of personnel. Although it is often included as part of the review of the entire incident, it should focus on how the entity’s response to the incident could be improved.

It is important to not just consider elements of the response that did not have the planned outcomes but also to understand what worked well and whether lessons from those elements that worked well can be applied areas of the plan that didn’t.

Another way to optimize an entity’s incident response plan is to understand the attacks made against other organizations and use that information to fine-tune the entity’s detection, containment, mitigation, or recovery procedures.

12.10.7 Incident response procedures are in place, to be initiated upon the detection of stored PAN anywhere it is not expected, and include: • Determining what to do if PAN is discovered outside the CDE, including its retrieval, secure deletion, and/or migration into the currently defined CDE, as applicable • Identifying whether sensitive authentication data is stored with PAN • Determining where the account data came from and how it ended up where it was not expected • Remediating data leaks or process gaps that resulted in the account data being where it was not expected

If PAN was found outside the CDE, analysis should be performed to 1) determine whether it was saved independently of other data or with sensitive authentication data, 2) identify the source of the data, and 3) identify the control gaps that resulted in the data being outside the CDE.

Entities should consider whether there are contributory factors, such as business processes, user behavior, improper system configurations, etc. that caused the PAN to be stored in an unexpected location. If such contributory factors are present, they should be addressed per this Requirement to prevent recurrence.

Key Takeaways

  • The security policy for the organization identifies the purpose, scope, accountability, and information that clearly defines the organization’s position regarding information security.
  • It is important that usage policies are supported by technical controls to manage the enforcement of the policies.
  • Structuring polices as simple “do” and “do not” requirements that are linked to a purpose can help remove ambiguity and provide personnel with the context for the requirement.
  • Examples of risk-assessment methodologies for enterprise-wide risk assessments include, but are not limited to, ISO 27005 and NIST SP 800-30.
  • Executive management assignment of PCI DSS compliance responsibilities ensures executive-level visibility into the PCI DSS compliance program.
  • If an entity keeps an inventory of all assets, those system components in scope for PCI DSS should be clearly identifiable among the other assets.
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