Input:
	Background

Information security is a critical consideration for any agency that  depends on information systems and computer networks to carry out its  mission and is especially important for a federal agency such as FDA,  which collects, processes, and stores sensitive information on drugs and  other products pending approval; the safety of food, drug, and medical  products; and scientific research to inform regulatory decisions. While the  use of interconnected electronic information systems allows the agency to  accomplish its mission more quickly and effectively, this also exposes  FDA’s information to threats from sources internal and external to the  agency. Internal threats can include errors, as well as fraudulent or  malevolent acts by employees or contractors working within the agency.  External threats include the ever-growing number of cyber-based attacks  that can come from a variety of sources, including hackers, criminals,  foreign nations, terrorists, and other adversarial groups.
Potential cyber attackers have a variety of techniques at their disposal,  which can vastly enhance the reach and impact of their actions. For  example, these attackers do not need to be physically close to their  targets, their attacks can easily cross state and national borders, and they  can more readily preserve their anonymity. Additionally, advanced  persistent threats—where an adversary that possesses sophisticated  levels of expertise and significant resources can use physical and cyber  methods to achieve its objectives—pose increasing risks. Further, the  interconnectivity among information systems presents increasing  opportunities for such attacks.
This risk is highlighted by the rising number of reported security incidents  at federal agencies. Specifically, the number of incidents reported by  federal agencies to the United States Computer Emergency Readiness  Team (US-CERT) has increased dramatically in recent years. It rose  from 5,503 in fiscal year 2006 to 77,183 in fiscal year 2015.
Compounding the growing number and types of threats are the  deficiencies in security controls on the information systems at federal  agencies. These weaknesses have resulted in vulnerabilities in systems  and information and continue to place assets at risk of inadvertent or  deliberate misuse; information at risk of unauthorized access,  modification, or destruction; and critical operations at risk of disruption.
Accordingly, we have designated federal information security as a  government-wide high-risk area since 1997, and in 2003 expanded this  area to include computerized systems supporting the nation’s critical  infrastructure. In February 2015, we further expanded this area to include  protecting the privacy of personal information that is collected,  maintained, and shared by both federal and nonfederal entities. In  September 2015, we reported that more than half of the 24 major federal  agencies continued to experience weakness in the controls intended to  preserve confidentiality—preventing unauthorized access to information  and systems; integrity—preventing unauthorized modification or  destruction of information, including access and configuration controls;  and availability—ensuring timely and reliable access to and use of  information when needed, such as contingency planning controls.
To improve federal information security, the Federal Information Security  Modernization Act (FISMA) was enacted in 2014. The law is intended to  address the increasing sophistication of cybersecurity attacks, promote  the use of automated security tools with the ability to continuously monitor  and diagnose the security posture of federal agencies, and provide for  improved oversight of federal agencies’ information security programs.  FISMA provides a comprehensive framework for ensuring the  effectiveness of information security controls over information resources  that support federal operations and assets.
Among other things, FISMA requires federal agencies to develop,  document, and implement an agency-wide information security program.  Agencies are to carry this out using a risk-based approach to information  security management. Such a program includes developing and  implementing cost-effective security policies, plans, and procedures;  assessing risk; providing specialized training; testing and evaluating the  effectiveness of controls; planning, implementing, evaluating, and  documenting remedial actions to address information security  deficiencies; and ensuring continuity of operations.
FISMA also gives the National Institute of Standards and Technology  (NIST) responsibility for developing standards and guidelines that include  minimum information security requirements. To this end, NIST has issued  numerous publications to provide guidance for agencies in implementing  an information security program. These include, among others, the NIST  Federal Information Processing Standard (FIPS) 199, which provides  requirements for agencies to categorize their systems and information,  and NIST Special Publication (SP) 800-53, which provides guidance on  the selection and implementation of information security and privacy  controls for systems.

		FDA Is Responsible for Ensuring the Safety, Effectiveness, and Quality of Food and Medical Products

FDA is a consumer protection agency with broad regulatory authority  charged with protecting public health by ensuring the safety,  effectiveness, and security of human veterinary drugs, biological  products, and medical devices; ensuring the safety of foods, cosmetics,  and radiation-emitting products; and regulating tobacco products.
FDA’s mission includes helping to speed innovations that make foods  safer and medicines and medical devices safer and more effective;  ensuring members of the public have accurate, science-based  information they need to use medicines, devices, and foods to improve  their health; regulating the manufacture, marketing, and distribution of  tobacco products and reducing tobacco use by minors; and addressing  the nation’s counterterrorism capability by ensuring the security of the  supply of foods and medical products.
FDA performs regulatory activities that include  reviewing and approving new drugs and certain medical products;  inspecting manufacturing facilities for compliance with regulations and  good manufacturing practices; and  conducting post-market surveillance of food, drug, and medical  products to ensure they are safe; tracking and identifying the source  of outbreaks of foodborne illnesses; and issuing recall notices and  safety alerts for products that threaten the public health.
According to FDA, its fiscal year 2015 appropriation was $4.5 billion. The  agency is headed by a Commissioner and is staffed by more than 14,000  employees across the United States and around the world. FDA consists  of its Office of the Commissioner and four directorates that oversee the  agency’s core functions. These directorates are the Office of Foods and  Veterinary Medicine, Office of Global Regulatory Operations and Policy,  Office of Medical Products and Tobacco, and Office of Operations. Within  these directorates are offices and centers that focus on core parts of the  agency’s mission. Examples of these offices and centers are shown in  table 1.

		FDA Relies on Computer Systems to Support Its Mission

FDA relies extensively on IT to fulfill its mission and support related  administrative needs. Among the more than 80 systems reported in its  FISMA inventory, the agency has systems dedicated to supporting its  product review and evaluation activities, regulatory compliance functions,  and product safety monitoring activities, as well as systems to support  administrative processes. All of these systems are supported by an IT  infrastructure that includes network components, critical servers, and data  centers.
In fiscal year 2015, the agency reported spending $585 million on IT, of  which approximately $12 million (or about 2 percent of the IT budget) was  for information security. This percentage is lower than the approximately  8 percent of their fiscal year 2015 IT spending that the 23 civilian  agencies covered by the Chief Financial Officers Act reportedly spent on  information security. For fiscal year 2016, FDA requested $640 million for  IT and $16 million for information security. In addition, FDA indicated that  real-time connectivity and access to data and information is essential for  its daily operations, as well as its interactions with the public and other  partners. These factors depend on high-quality, high-availability, and  high-performing data networks, server and application infrastructure,  communications services, simple and complex computer applications,  mobile workforce capabilities, and rapid and responsive service delivery.
Examples of the processing activities that key FDA systems perform in  supporting of the agency’s mission are listed below:
Support and facilitate post-market product safety surveillance of  human drugs, biologics, devices, and combination products. Provide a  data repository for collecting, storing, viewing, analyzing, reporting,  and tracking the receipt of adverse event data or medication errors.
Establish a single gateway or communications portal for accepting  electronic submissions or allowing authorized users to view or obtain  information. Examples of electronic submissions include industry- provided trade secrets, adverse event records, and a multitude of  different records related to FDA’s regulatory oversight of regulated  products.
Provide capabilities for regulatory scientific research, while also  supporting FDA’s overall goals and objectives in areas where  information technology requires supercomputer-strength  computational power.
Support FDA’s research and development activities.
Provide a platform through which FDA organizations may disseminate  FDA-related information to interested parties, including the public,  health professionals, regulated industries, and the media. Provide  information about the various product areas that FDA regulates (food,  drugs, medical devices, cosmetics, etc.), timely advisories (e.g.,  anticipated disease outbreaks such as the Severe Acute Respiratory  Syndrome (SARS), buying medicines online, and LASIK surgery), and  other FDA activities. Provide links to related reference materials and  opportunities for consumers and industry to interact with the FDA.
Provide basic network and security capabilities for the FDA enterprise.
Facilitate receipt and review of electronic drug applications. This  function includes scans and checks of the validity of drug submissions  from industry and making them available for reviewers, as well as  providing file shares for storing successful submissions that are to be  reviewed.
In addition, FDA contractors support data centers and systems that  provide, among other things, the network infrastructure for the agency’s  systems and its public website. The information handled by these  systems includes sensitive or confidential business information on drug  submissions and adverse event reports, among other types of  information.
Accordingly, effective implementation of security controls is necessary to  protecting the confidentiality, integrity, and availability of FDA’s  information and in preventing the occurrence or lowering the risks of  security breaches similar to one the agency experienced in 2013. During  that breach, an intruder gained unauthorized access to one FDA system’s  user accounts and passwords. Effective controls can help ensure only  authorized users (people and processes) access information and systems  to lessen the chances of unauthorized disclosures of information,  improper changes or modifications to FDA’s information and systems,  and system disruptions that could hamper the agency’s ability to perform  its mission.
To improve the management of FDA’s information systems security and  operations, the agency, in fiscal year 2015, consolidated its network and  security operations centers to reorganize the Systems Management  Center (SMC). According to FDA, the SMC is the central command and  control center and is intended to help establish real-time network  awareness to forecast, detect, alert, and report events such as security  incidents and facilitate the coordination requirements of its Office of  Information Management and Technology. In addition, the agency  reported that it established a cybersecurity task force to address short- and long-term concerns with protecting its network boundaries.

		Information Security Responsibilities at FDA

Under FISMA, the Commissioner of FDA is responsible for ensuring the  confidentiality, integrity, and availability of the information and systems  that support the agency and its operations. FISMA also requires that the  agency head delegate to the chief information officer (CIO) the overall  responsibility for management of the agency’s IT security program. At  FDA, the CIO is responsible for evaluating the overall mission  requirements for an IT system or application and ensuring that it complies  with FDA IT security policies, guidelines, and standards. The CIO is also  responsible for, among other things, ensuring effective implementation of FDA’s IT Security Policy;  formally appointing a Chief Information Security Officer (CISO) and  ensuring that individual complies with FDA’s IT security regulations  and guidelines; ensuring that IT security is included in management planning,  programming budgets, and the IT capital planning process; and ensuring that annual security reviews are conducted to include annual  review and update of security policies and reporting of IT systems to  the Office of Management and Budget (OMB).
In addition, FDA’s IT Security Program is headed by the agency’s CISO,  who is responsible for ensuring that adequate and appropriate controls  are applied to FDA systems for the protection of privacy, and to ensure  confidentiality, integrity, and availability, of information. The CISO is to  employ security policies and standards for FDA information systems  enterprise-wide in accordance with FDA, HHS, OMB, NIST, and other  federal security requirements. The CISO also provides guidance on IT  system security matters to the Information Systems Security Officers  (ISSO) in the center/office they support.
At FDA, ISSOs are responsible for ensuring the implementation of  adequate system security for each system supporting a particular center  or office. Every center or office system is to have an ISSO assigned as  the point of contact for security. Among other things, FDA ISSOs’  responsibilities include (1) ensuring that FDA systems are operated,  used, maintained, and disposed of in accordance with FDA’s security  policies and procedures; (2) ensuring system security plans are  completed and maintained; (3) assisting with system authorization; (4)  responding to and reporting security incidents; (5) promoting security  awareness; and (6) ensuring media handling procedures are followed.

	Security Weaknesses Place Seven FDA Systems and Sensitive Data at Risk

FDA has taken steps to safeguard its systems that receive, process, and  maintain sensitive data by, for example, implementing policies and  procedures for controlling access to and securely configuring those  systems. However, a significant number of weaknesses remain in  technical controls—including access controls, change controls, and patch  management—that jeopardize the confidentiality, integrity, and availability  of its systems. An underlying reason for these weaknesses is that FDA  had not yet fully implemented an agency-wide information security  program to provide reasonable assurance that controls were operating  effectively. These shortcomings put FDA systems at increased and  unnecessary risk of unauthorized access, use, or modification that could  disrupt its operations. To its credit, FDA, during the course of our work,  immediately resolved some of the weaknesses identified and provided  information on its proposed actions to address the underlying  weaknesses in controls.

		FDA Did Not Fully Implement Access Controls

Access controls are designed and implemented to provide reasonable  assurance that an agency’s computerized information is reliable. Both  logical and physical access controls are intended to prevent, limit, and  detect unauthorized access to computing resources, programs,  information, and facilities. Access controls include those related to (1)  protection of system boundaries, (2) identification and authentication of  users, (3) authorization of access permissions, (4) encryption of sensitive  information, (5) audit and monitoring of system activity, and (6) physical  security of facilities.
As shown in table 2, weaknesses existed in each of these areas for the  systems we reviewed. In a separate report with limited distribution, we  describe these weaknesses in more detail, along with associated  recommendations.
Inadequate design or implementation of access controls increases the  risk of unauthorized disclosure, modification, and destruction of sensitive  information and disruption of service.

			FDA Did Not Always Adequately Protect Its Network Boundaries

Boundary protection controls logical connectivity into and out of networks  and controls connectivity to and from devices connected to the network.  For example, multiple firewalls can be deployed to prevent both outsiders  and trusted insiders from gaining unauthorized access to systems, and  intrusion detection technologies can be deployed to defend against  attacks from the Internet. Unnecessary connectivity to an organization’s  network increases not only the number of access paths that must be  managed and the complexity of the task, but also the risk of unauthorized  access in a shared environment.
NIST recommends that agencies implement subnetworks to separate  publicly accessible system components from their internal networks.  NIST also states that agencies should provide adequate protection for  networks and employ information control policies and enforcement  mechanisms to control the flow of information between designated  sources and destinations within information systems. Similarly, NIST  recommends that organizations monitor and control communications at  information systems’ external boundaries and at key internal boundaries  within a system.
FDA did not always adequately ensure that its network boundaries were  sufficiently segregated. For example, the contractor supporting the  agency’s public-facing website did not isolate the agency’s network from  its own network and that of its other customers, which included non-FDA  customers. In addition, the contractor did not configure firewall rules to  restrict access into FDA’s internal network.
In another example, FDA did not sufficiently restrict inbound connections  from one of its untrusted networks and isolate that network from its  internal network. The network was untrusted because the agency had not  developed and implemented risk management controls for the system.  As a result, it poses increased risks to other agency systems.
Further, as illustrated in the following examples, FDA did not always  implement other boundary controls.
Network devices at the agency’s field locations were not properly  configured and allowed all remote access protocols, such as the  unsecure telnet protocol.
Routers at certain international locations were not configured to  restrict inbound management traffic from untrusted sites.
Host-based firewalls for four key systems and some workstations  were not effectively configured to permit only necessary traffic and  provide protection from malicious activity.
As a result, sensitive public health, proprietary business, and personal  information maintained by the agency were at increased risk of  compromise due to inadequate separation of the service provider’s  network from FDA’s network, inadequate separation of the untrusted  network from the agency’s network, and weaknesses in other boundary  controls.

			FDA Did Not Always Implement Controls for Identifying and Authenticating System Users

A computer system must be able to identify and authenticate different  users so that activities on the system can be linked to a specific  individual. When an organization assigns a unique user account to a  specific user, the system is able to distinguish that user from another—a  process called identification. The system must also establish the validity  of a user’s claimed identity by requesting some kind of information, such  as a password, that is known only by the user—a process known as  authentication. The combination of identification and authentication—such  as a user account/password combination—provides the basis for  establishing individual accountability and for controlling access to the  system.
NIST SP 800-53 recommends that password management controls  should be established for information systems that include minimum  password complexity requirements, password lifetime restrictions,  prohibitions on password reuse, and user accounts to be temporarily  locked out after a certain number of failed login attempts during a  specified period of time. Further, FDA password policy outlines  requirements consistent with this guidance.
NIST also states that agencies can satisfy certain identification and  authentication requirements by complying with the requirements in  Homeland Security Presidential Directive 12 and using multifactor  authentication such as personal identity verification cards. Multifactor  authentication requires the use of two or more different factors to achieve  authentication. The factors are defined as something you know (e.g., a  password or a personal identification number); something you have (e.g.,  cryptographic identification device or token); or something you are (e.g.,  biometric).
FDA implemented personal identity verification cards for multifactor  authentication; however, the agency did not always implement strong  password controls in accordance with its security policies and NIST  guidance on five of the seven systems we reviewed. For example, three  local accounts on a database server which contained certificates used to  encrypt industry partner submission packages had passwords that had  not been changed in more than 5 years. In addition, several service  accounts for servers with access to sensitive industry partner regulatory  submissions had passwords set to never expire. Further, a Windows  administrator’s non-privileged account was unnecessarily elevated to a  privileged account by being part of an administrators group. These  accounts are used to administer users’ logical access inside FDA  mission-critical systems that process confidential business information or  trade secrets such as that for drug submissions and adverse event  reporting. In another example, the password to a service account for  synchronizing user passwords was set to never expire and had not been  changed in the last 6 years.
In addition, FDA did not always implement password controls on certain  network devices. For example, password management settings were set  to default values on two network devices that delivered web applications  to FDA users. These default settings were for local accounts, including  web administrator and root accounts, and included minimum password  lengths set to six characters, with no requirements for password  complexity, maximum password lifetime days, password history, and  invalid attempts. In another example, a user account password for a  network management server that monitors and maintains a history of  network devices’ hardware and software changes had not been changed  since January 6, 2011. Without implementing strong password  requirements, increased risk exists that passwords could be guessed,  permitting unauthorized access to FDA systems.

			FDA Users Had More Access to Information than Necessary for Official Duties

Authorization is the process of granting or denying access rights and  permissions to a protected resource, such as a network, a system, an  application, a function, or a file. For example, operating systems have  built-in authorization features such as permissions for files and folders.  Network devices, such as routers, have access control lists that can be  used to authorize a user who can access and perform certain actions on  the device. A key component of granting or denying access rights is the  concept of “least privilege.” Least privilege is a basic principle for securing  computer resources and information. This principle means that a user is  granted only those access rights and permissions needed to perform  official duties. To improve authorization controls, the Federal CIO  instructed agencies, as part of the Cybersecurity Sprint, to tighten  policies and practices of privileged users. These steps included, for  example, minimizing the number of privileged users and limiting functions  that can be performed when using privileged accounts. To avoid  unintentionally authorizing user access to sensitive files and directories,  an agency must give careful consideration to its assignment of rights and  permissions.
NIST Special Publication 800-53 recommends that agencies should grant  user accounts only those privileges required for the users to perform their  job functions. Additionally, FDA policy states that access to sensitive  information must be restricted and based on the concept of need-to-know.
Although FDA has developed and documented access control  requirements based on least privilege and need-to-know principles, users  were granted excessive permissions that were not needed for their official  duties. These permissions enabled administrators and users who did not  need such permissions with the authority to read, and in some cases,  write and modify submissions that could contain sensitive or confidential  business information on drug submissions or adverse event reporting, as  illustrated below.
Forty-nine administrators and users with access to 392 production  servers had, by default, unnecessary access to file shares containing  industry submissions on adverse events.
A group account allowed 753 users unneeded access to adverse  event data submissions.
Ninety-two desktop users, via a group account, had unauthenticated  access to one key system’s file shares.
4,534 users, which included regulatory reviewers and project  managers, had uncontrolled “read access” to file shares on the  system that handles sensitive regulatory drug and biologic product  submissions.
According to FDA, the high number of users with access was necessary  due to the high volume of regulatory submissions reviewed daily, which  regularly exceeds 1,500 per day, and because staff must often access  multiple sponsor submissions in order to complete their regulatory review  in a timely manner.
However, for the data we reviewed, only about 2,400 users per month  accessed these files, compared with the 4,534 users who were granted  access. Moreover, FDA did not restrict access to privileged users groups  by, for example, differentiating high-valued submission assets from low- valued ones, even though the system stored highly sensitive industry  trade secret information.
In addition, for this same system, FDA allowed 39 users in the  administration group and 104 users in the staff group to have read, write,  and modify privileges to the submission files. The server can be accessed  without a user interface and FDA does not have visibility of users’ access  to the submission files on the server.
As a result, FDA was at increased risk that users could inadvertently or  deliberately modify these files and jeopardize the integrity of the  submitted information.

			FDA Did Not Always Encrypt Certain Sensitive Data

Cryptography underlies many of the mechanisms used to enforce the  confidentiality and integrity of critical and sensitive information.  Cryptographic tools help control access to information by making it  unintelligible to unauthorized users and by protecting the integrity of  transmitted or stored information. A basic element of cryptography is  encryption. Encryption is the conversion of data into a form, called a  cipher text, which cannot be easily understood. Encryption can be used to  provide basic data confidentiality and integrity by transforming plain text  into cipher text using a special value known as a key and a mathematical  process known as an algorithm. NIST SP 800-53 states that agencies  should use encryption to protect the confidentiality of remote access  sessions and they should encrypt sessions between host systems. The  NIST standard for an encryption algorithm is Federal Information  Processing Standard (FIPS) 140-2.
FDA did not always ensure that sensitive data were effectively encrypted  when transmitted or stored. For example, 59 network devices we  reviewed had weak non-FIPS-compliant algorithms to encrypt user  passwords. In addition, a web server supporting the receipt of industry  submissions and a database server storing certificates to support secure  connections for receiving submissions used non-FIPS-compliant  algorithms to encrypt passwords. Furthermore, the web server’s  password file was encrypted by an algorithm that was outdated and had  been withdrawn by NIST over 10 years ago.
As a result of using weak encryption algorithms, FDA is at increased risk  that user passwords may be easier to crack and used by unauthorized  individuals to gain access to systems and sensitive information.

			FDA Did Not Always Audit and Monitor Activity on Its Systems

To establish individual accountability, monitor compliance with security  policies, and investigate security violations, agencies need to determine  what, when, and by whom specific actions have been taken on a system.  Agencies can accomplish this by implementing system or security  software that provides an audit trail (a log of system activity) that is used  to determine the source of a transaction or attempted transaction and to  monitor a user’s activities. Audit and monitoring, key components of risk  management, involve the regular collection, review, and analysis of  auditable events for indications of inappropriate or unusual activity, and  the appropriate investigation and reporting of such activity.
Audit and monitoring controls can help security professionals routinely  assess computer security, perform investigations during and after an  attack, and even recognize an ongoing attack. Audit and monitoring  technologies include network- and host-based intrusion detection  systems, audit logging, security event correlation tools, and computer  forensics. NIST guidelines state that agencies should retain sufficient  audit logs to allow monitoring of key activities, provide support for after- the-fact investigation of security incidents, and meet agency information  retention requirements.
FDA did not always implement and integrate auditing and monitoring for  the seven systems we reviewed. For example, the agency did not have  network monitoring visibility across its entire network. Specifically, it did  not monitor IT assets used by a contractor supporting the system that  provides the agency’s Internet and public network. In addition, the agency  did not always audit or monitor system activity on IT assets for networks  supporting scientific research and high-performance computing.
The agency also did not always retain audit logs to allow monitoring of  key activities and provide support for after-the-fact investigation of  security incidents. To illustrate, databases supporting drug submissions  and adverse event reporting did not have logging enabled for monitoring  the use of special system privileges such as alter, create, and grant.
Further, FDA did not retain all records of evidence related to a 2013  security breach from an external attack on an FDA Internet application  that allowed the attacker to gain access to a backend database and  exfiltrate sensitive users account information. Specifically, it did not retain  digital forensics data related to the attack commands and the review of  dates and times of files and database entries relevant to data exfiltration  of users’ account data. Such information could be useful in better  understanding what occurred and in preventing future occurrences.
As a result, FDA did not have information necessary for monitoring key  database activities and supporting after-the-fact investigations of security  incidents. In addition, the lack of evidence could prevent the agency from  determining what events occurred within its systems and networks, such  as lateral movements by an attacker that may occur from initial entry into  a network to network discovery, hosts targeting, and data exfiltration  activities to external systems.

			FDA Did Not Update Physical Security Policies or Conduct Reviews of Facilities

Physical security controls restrict physical access to computer resources  and protect them from intentional or unintentional loss or impairment.  Adequate physical security controls over computer resources (e.g.,  computer facilities, network devices such as routers and firewalls,  telecommunications equipment, and transmission lines) should be  established that are commensurate with the risks of physical damage or  access. NIST SP 800-53 recommends that agencies review and update  the current physical and environmental protection policy at an  organization-defined frequency and conduct an assessment of risks,  including the likelihood and magnitude of harm, to the information system  and information it processes, stores, or transmits.
Consistent with federal guidance, FDA’s Information System Security and  Privacy Guide states that physical and environmental protection policies  are to be reviewed and updated every 3 years. In addition, the agency’s  policies for its facilities state that annual physical security reviews are to  be conducted. These reviews are to include, among other things,  reviewing security measures in effect to compensate for any  noncompliance with requirements, and corrective actions initiated or  planned to eliminate deficient conditions.
While FDA developed and documented physical security policies for its  facilities, they had not been reviewed and updated for about 14 years. For  example, the physical security policy for its headquarters facilities was  dated February 2001, and the physical security policy for field activities  was dated October 2000. Neither of these policies had been reviewed  and updated since they were established, even though the agency’s  policy requires this to occur every 3 years. In addition, the agency had not  conducted required annual physical security reviews of three of its data  center facilities. FDA only provided documentation to support that it had  reviewed one of them, which occurred in July 2013 and was not within the  annual requirement.
According to FDA’s CISO and a policy analyst, gaps in reviewing and  updating policies and procedures were due to personnel resource  constraints and a lack of a streamlined process to review policy and  procedures at the agency. As a result, FDA has diminished assurance  that its computing resources are protected from inadvertent or deliberate  misuse or damage.

		FDA Conducted Background Investigations, but Weaknesses in Other Controls Increased Risk

In addition to access controls, other important controls should be in place  to provide reasonable assurance that the confidentiality, integrity, and  availability of an agency’s information is protected. These controls include  policies, procedures, and techniques for (1) implementing personnel  security, such as background investigations, (2) managing and  implementing system configurations, (3) effectively planning for system  contingencies, and (4) developing and implementing procedures for  disposing of media containing sensitive information. While FDA  conducted background investigations according to its policy, weaknesses  in other controls increased the risk of unauthorized use, disclosure,  modification, or loss of the FDA’s mission-sensitive information.

			FDA Conducted Background Investigations for the Personnel Reviewed

The greatest harm or disruption to a system can often come from the  actions, both intentional and unintentional, of individuals. These  intentional and unintentional actions can be reduced through the  implementation of security controls over personnel. Background checks  should be done prior to an individual’s authorization to access information  systems, and personnel in sensitive positions should be periodically  rescreened. Furthermore, FDA policy requires positions to be designated  by sensitivity and risk level, and describes requirements for conducting  background investigations for employees and contractors, including  periodic reinvestigations of individuals in positions of higher risk or  sensitivity.
FDA conducted background investigations for the employees and  contractors we reviewed. Specifically, each of the 14 employees and  contractors we selected had up-to-date background investigations that  were consistent with the risk designation of their positions. As a result,  FDA reduced its risk that it has employed or contracted for individuals  with unsuitable backgrounds for accessing its systems.

			FDA Did Not Always Implement Controls for Configuration Management

Configuration management is an important control that involves the  identification and management of security features for all hardware and  software components of an information system at a given point and  systematically controls changes to that configuration during the system’s  life cycle. Configuration management involves, among other things, (1)  verifying the correctness of the security settings in the operating systems,  applications, or computing and network devices and (2) obtaining  reasonable assurance that systems are configured and operating  securely and as intended. In addition, establishing controls over the  modification of information system components and related  documentation helps to prevent unauthorized changes and ensure that  only authorized systems and related program modifications are  implemented. This is accomplished by instituting policies, procedures,  and techniques that help make sure that all hardware, software, and  firmware programs and program modifications have been properly  authorized, tested, and approved.
According to NIST SP 800-53, configuration management activities  should include documenting approved configuration-controlled changes to  information systems, retaining and reviewing records of the changes,  auditing those records, and coordinating and providing oversight for  configuration change control activities through a mechanism such as a  change control board. Patch management, a component of configuration  management, is important for mitigating the risks associated with known  software vulnerabilities. When a software vulnerability is discovered, the  software vendor may develop and distribute a patch or work-around to  mitigate the vulnerability. Without the patch, an attacker can exploit the  vulnerability to read, modify, or delete sensitive information; disrupt  operations; or launch attacks against other systems. Outdated and  unsupported software is more vulnerable to attack and exploitation  because vendors may no longer provide updates, including security  updates, to correct software flaws.
FDA has developed, documented, and established policies and  procedures to manage configuration changes. In addition, for the systems  we reviewed, FDA officials demonstrated that system changes were first  requested, tracked, and approved at the system level prior to being  forwarded via an automated tool to FDA’s change control board as  required by policy. However, FDA officials could not provide  documentation to demonstrate that emergency changes to software code  to remediate security vulnerabilities were tested, validated, and  documented in response to the 2013 breach of its Internet-facing web  application. Further, the agency did not always implement secure  configuration settings for its systems. For example:
FDA did not appropriately configure 336 devices, which could prevent  proper identity enforcement of these network devices and could allow  unauthorized access to other networks and devices.
FDA used out-of-date and unsupported software on servers storing  sensitive data on industry partner regulatory submissions for several  of the systems we reviewed. In addition, Windows file share servers  and other application servers on several systems we reviewed were  out of date and had reached end-of-life, in some cases for more than  4 years past the support date.
Two firewalls for managing contractors’ access to FDA’s network had  operating system versions that were close to end-of-life for support,  and FDA had no mitigation plans in place to manage this risk.
Similarly, FDA has developed, documented, and established a policy for  managing patches that includes time frames for applying patches based  on risk, and emergency and out-of-cycle patches within 48 hours of  discovery. However, FDA did not always document emergency changes  to software code on an application that supported its Internet services.  These changes were made in response to an external Internet attack that  resulted in a breach of the system’s user account data.
In addition, software security updates and patches were not always  installed to address known security vulnerabilities, nor were they timely.  For example:
FDA had not applied security updates and patches for network  devices, switches, firewalls, specialized network devices, and servers,  as well as contractor-operated network devices, in accordance with  NIST’s Common Vulnerability Scoring System (CVSS) guidelines for  patching devices. CVSS prescribes that patches be installed within 30  days for critical or high-risk vulnerabilities, 60 days for moderate-risk  vulnerabilities, and 90 days for low-risk vulnerabilities. FDA’s policy  also requires that they follow these patching time frames. However,  hundreds of these devices had not been updated with the latest  patches in over 3 years.
The agency had not patched 25 servers supporting its infrastructure.
For example, one sever had not been patched for 6 months, from  February to August of 2015.
FDA had not applied critical security patches to 74 of 82 host virtual  servers supporting its infrastructure. In some cases these patches  contained major updates to fix multiple security vulnerabilities.
Various file share servers for three FDA systems we reviewed had not  been patched since 2009.
Without proper implementation of configuration management policies and  procedures and adequate security controls, FDA systems are susceptible  to many known vulnerabilities.

			FDA Did Not Always Plan for Contingencies

Losing the capability to process, retrieve, and protect electronically  maintained information can significantly affect an agency’s ability to  accomplish its mission. If contingency planning is inadequate, even  relatively minor interruptions can result in lost or incorrectly processed  data, which can cause financial losses, expensive recovery efforts, and  inaccurate or incomplete information. Contingency planning consists of  interim measures to recover information system services after a  disruption. Interim measures may include relocation of information  systems and operations to an alternate site, recovery of information  system functions using alternate equipment, or performance of  information system functions using manual methods.
NIST SP 800-53 recommends that agencies establish a contingency  planning policy in the event of unplanned disruptions and provide  contingency training and exercises at an agency-defined frequency,  among other things. In addition, NIST SP 800-34 recommends that a test  plan should be designed and tested to examine applicable contingency  planning elements such as notification procedures and system recovery  on an alternate platform from backup media to validate the contingency  capability. Further, FDA policy also requires functional testing of its  contingency plans annually.
Consistent with NIST guidelines, FDA’s Information System Security and  Privacy Guide states that contingency planning policies are to be updated  every 3 years, while information system contingency plans are to be  reviewed annually. FDA’s policy also requires that contingency plans be  tested on an annual basis.
However, FDA did not follow its own requirements for updating and  reviewing contingency policy and plans. For example, FDA’s contingency  planning policy was established in 2007 but was still marked as a draft  document and had yet to be reviewed and updated. Further, FDA did not  review, at least annually, the contingency plans for six of the seven  applications and general support systems that we reviewed during fiscal  year 2015 and had not developed and documented a contingency plan for  the seventh system.
In addition, FDA did not adequately test five of the six contingency plans  we reviewed. For example:
For two major applications, FDA conducted procedures to mitigate  system disruptions and documented those activities as tests.  However, the actions performed to mitigate disruptions were not  based on planned tests.
A planned migration was conducted for a general support system to  transfer operations to a facility. However, this migration was not the  result of a planned contingency test.
The plans for two general support systems had not been tested since  2013. However, the tests did appropriately assess elements such as  notification procedures, and system recovery.
FDA staff attributed these weaknesses to the lack of a streamlined  process for reviewing policies and procedures, and personnel resource  constraints such as the lack of contracted staff to support FDA  contingency planning and operations during an organizational transition.
By not finalizing its contingency planning policy and not annually  reviewing and testing contingency plans, FDA has reduced assurance  that it has implemented controls necessary for effectively continuing  operations in the event of a disruption.

			FDA Had Not Developed and Implemented Media Sanitization Procedures

The destruction of media and its disposal are key to ensuring the  confidentiality of information. Media can include magnetic tapes, optical  disks (such as compact disks), and hard drives. Agencies safeguard used  media to ensure that the information they contain is appropriately  controlled or disposed of. Media that is improperly disposed of can lead to  the inappropriate or inadvertent disclosure of an agency’s sensitive  information or the personally identifiable information of its employees and  customers.
NIST SP 800-53 recommends that agencies sanitize media prior to  disposal and employ sanitization mechanisms to ensure information  cannot be retrieved or reconstructed. FDA’s policy for sanitizing  computer-related storage media, including server backup tapes, states  that techniques used to sanitize media can include degaussing, among  other things.
However, FDA did not sanitize media backup tapes that were being  stockpiled for disposal. Specifically, for two data center locations, media  tapes were stored outside of servers and scheduled for sanitization, but  had yet to be sanitized and disposed of. At one of the two data centers,  we observed a number of older tapes, and FDA staff said these tapes  were awaiting disposal. Specifically, staff mentioned that the legacy tapes  held data from operations in prior location and were in a “holding pattern”  and tentatively scheduled for decommission. Similarly, FDA staff from the  second data center acknowledged that approximately 900 tapes were  also awaiting disposal and that these tapes contained older servers,  databases, and files resulting from a migration to updated servers tapes.
According to the data center staff, the agency had not developed,  documented, and implemented a procedure for sanitizing media, but  planned to have a solution by October 2016. Until FDA fully implements a  process for media sanitization, the agency is at an increased risk that its  sensitive information may not be adequately protected.

		FDA Did Not Fully Implement Its Information Security Program, Limiting the Effectiveness of Information Security Controls

A key reason for the weaknesses in controls over FDA’s information and  information systems is that it has not yet fully implemented its agency- wide information security program to ensure that controls are effectively  established and maintained. If an agency does not fully implement its  program, security controls may be inadequate or inconsistently applied;  responsibilities may be unclear, misunderstood, or improperly  implemented; and organizational and system risks may not be assessed  and monitored properly. FISMA requires each agency to develop,  document, and implement an information security program that, among  other things, includes a periodic assessment of risk and magnitude of harm that could result  from the unauthorized access, use, disclosure, disruption,  modification, or destruction of information or information systems; policies and procedures that (1) are based on risk assessments, (2)  cost-effectively reduce information security risks to an acceptable  level, (3) ensure that information security is addressed throughout the  life cycle of each system, and (4) ensure compliance with applicable  requirements;  subordinate plans for providing adequate information security for  networks, facilities, and systems or a group of information systems, as  appropriate;  security awareness training to inform personnel of information security  risks and of their responsibilities in complying with agency policies  and procedures, as well as training personnel with significant security  responsibilities for information security; periodic testing and evaluation of the effectiveness of information  security policies, procedures, and practices, to be performed with a  frequency depending on risk, but no less than annually, and that  includes testing of management, operational, and technical controls  for every system identified in the agency’s required inventory of major  information systems; a process for planning, implementing, evaluating, and documenting  remedial actions to address any deficiencies in information security  policies, procedures, or practices; and procedures for detecting, reporting, and responding to security  incidents.
FDA has taken steps to implement an information security program and  manage information security risks for its major applications and general  support systems. However, key components of its information security  program have not been fully or consistently implemented.

			FDA Has Taken Steps to Assess Risks, but Some Practices Have Not Been Fully Implemented.

According to NIST SP 800-30, risk is determined by identifying potential  threats to the organization and vulnerabilities in its systems, determining  the likelihood that a particular threat may exploit vulnerabilities, and  assessing the resulting impact on the organization’s mission, including  the effect on sensitive and critical systems and data. Identifying and  assessing information security risks are essential to determining what  controls are required. Moreover, by increasing awareness of risks, these  assessments can generate support for the policies and controls that are  adopted in order to help ensure that the policies and controls operate as  intended.
FDA policy requires that risk assessment results for its systems be  reviewed annually, and risk assessments be updated prior to issuing a  new authority to operate, whenever there are significant system  changes, or every 3 years. FDA’s assessment of risk is conducted as part  of its security assessments.
Although FDA assessed risk for six of the seven systems we reviewed, it  did not document the likelihood that a particular threat could exploit  system vulnerabilities. For example, FDA only identified information  system control weaknesses and vulnerabilities for six of the reviewed  systems, but did not determine the likelihood and impact of threats to  those systems. For the seventh system, FDA did not assess risk or issue  a formal authority to operate. Finally, two of the six risk assessments had  not been reviewed annually.
During the course of our work, FDA completed the annual review of the  risk assessment for one of the two systems, and we have verified this  action. However, until FDA completes comprehensive risk assessments  and reviews them annually, the agency will have less assurance that it  has identified the necessary controls to protect its assets.

			Policies and Procedures Were Not Always Complete or Had Not Been Reviewed in a Timely Manner

A key element of an effective information security program is to develop,  document, and implement risk-based policies, procedures, and technical  standards that govern the security over an agency’s computing  environment. Information security policy is essential to establishing roles,  responsibilities, and requirements necessary for implementing an  information security program. The supporting procedures provide the  information and guidance on implementing the policies. According to  NIST, an agency should develop policies and procedures for each of the  NIST families of security controls to facilitate the implementation of the  controls. Additionally, HHS and FDA policy require that policies be  reviewed every 3 years to ensure that they are sufficient and consistent  with federal requirements.
FDA generally took steps to develop and document policies and  procedures for its information security program, but did not always  document them or ensure procedures were complete. For example, while  the agency has developed policies to cover 17 of 18 NIST control  families, it did not develop one for system maintenance. In addition, the  agency did not develop or document procedures for implementing  controls in 8 of the 18 control families. The 8 control families were Audit  and Accountability, Identification and Authentication, Maintenance, Media  Protection, Physical and Environmental Protection, Security Planning,  Systems Communication and Protection, and System Information and  Integrity. Of the procedures for 10 control families that FDA provided, 3  were complete. However, procedures for 7 families were incomplete and  did not include steps suggested by NIST. For example, procedures for  security awareness and training did not include procedures for covering  role-based training, and those for assessment and authorization did not  address continuous monitoring as recommended by NIST.
Further, FDA did not review its policies according to its own requirements.  Specifically, 11 of 18 NIST-recommended policies were not reviewed  within the agency-defined frequency of 3 years. For example, the  agency’s personnel security policy was last reviewed in 1986. Policies for  other controls such as those for access controls, identification and  authentication, and incident response had not been reviewed in at least 7  years. FDA conducted an internal review in 2013 to identify the policies  that needed to be reviewed and updated, and had established a plan of  actions and milestones for updating them by November 2013. However,  the agency did not meet its own deadline for reviewing and updating 11 of  the 17 policies it had developed. According to FDA staff, the policies  had not been reviewed and updated because the process had been too  cumbersome and required a sign-off from a number of stakeholders.  FDA’s CISO also stated that they had been understaffed, which led to a  large backlog of policies to be reviewed.
Having incomplete policies and procedures or not reviewing them  reduces FDA’s assurance that roles and responsibilities have been  clearly assigned and understood and that personnel have the information  needed to implement its policies, which could lessen the agency’s ability  to efficiently and effectively protect its information systems.

			FDA Developed System Security Plans for Six of Seven Reviewed Systems, but They Were Incomplete and Not Annually Reviewed

FISMA requires that agencies develop and document system security  plans for all major federal information systems. This requirement should  be viewed as an essential part of planning adequate, cost-effective  security protection for a system. According to NIST, system security plans  should provide an overview of the security requirements of the system,  and document and describe the security controls and security control  enhancements in place or planned for meeting those requirements.  NIST also recommends that the plans be reviewed and approved by  authorizing officials or designated representatives. NIST states that plans  should be reviewed and updated at least annually to ensure that they  continue to reflect the correct information about the system such as  changes in system owners, interconnections, and authorization status,   among other things. Consistent with NIST, HHS and FDA policy  require FDA to review system security plans annually.
FDA created security plans and generally documented controls for six of  the seven applications and general support systems we reviewed.  However, the agency did not always ensure that the plans were complete,  or that plans were reviewed. For example, FDA did not always fully  describe the extent to which controls were implemented for each of the  six system security plans we examined. Specifically, it did not document  76 of 83 NIST-required high-impact control enhancements in the  security plan for the high-impact system used in reporting adverse events.  In addition, the agency did not document the control descriptions for 171  of 262 security controls and control enhancements; specifically, the  description of the implementation of 171 security controls and  enhancements was left blank in the plan for the system supporting FDA’s  infrastructure. The system has an important role in securing the agency’s  other systems since 68 of those systems inherit their controls from it. FDA  also did not demonstrate that any of the six plans we reviewed were  approved or reviewed by authorizing or senior agency officials.
According to an information system security officer, these shortfalls were  related to deficiencies in their security management tool and a lack of  resources. Officials stated that the tool that they used for entering  information into system security plans had software flaws, which did not  allow them to properly capture system security plan control descriptions;  officials stated that they plan to replace the tool but could not give a firm  timeline.
Until FDA develops and documents a plan for one system supporting its  research and updates system security plans to reflect current federal  control requirements, the agency lacks assurance that the appropriate  controls have been identified for the seven systems we reviewed and  increases the likelihood that the controls will not be fully implemented.

			FDA Provided Security Awareness Training but Did Not Always Track and Fully Train Users with Significant Security Responsibilities

According to FISMA, an agency-wide information security program must  include security awareness training for agency personnel, contractors,  and other users of information systems that support the agency’s  operations and assets. This training must cover (1) information security  risks associated with users’ activities and (2) users’ responsibilities in  complying with agency policies and procedures designed to reduce these  risks. FISMA also includes requirements for training personnel who have  significant responsibilities for information security. According to NIST,  agencies should also document and monitor individual information system  security training activities, including basic security awareness training and  specialized information system security training.
Consistent with federal law and guidelines, FDA’s Information System  Security and Privacy Control Parameters Guide states that the agency  should provide role‐based security‐related training to all personnel with  significant information security responsibilities. The agency’s policy also  requires that employees with significant security responsibilities  participate in role-based training appropriate to their security role before  receiving access to the system, when required by system or role changes  and every 3 years thereafter.
FDA tracked and provided security awareness training in fiscal years  2015 and 2016 to each of the 16 users we selected for review. The  agency tracks its user awareness training through a vendor-provided  web-based application. According to FDA, it previously provided  awareness training to about 98 percent of its users during fiscal year  2015.
However, the agency did not always track role-based training for those  with significant security responsibilities. For example, FDA’s tracking  system only identified 6 of the 16 individuals selected as having received  role-based training. According to FDA personnel, the resulting list was not  complete because the agency is re-engineering its process for tracking  compliance of specialized security training.
In addition, it did not fully provide role-based training to those with  significant security responsibilities. FDA demonstrated that 6 of the 16  individuals with significant security responsibilities we reviewed received  specialized IT training. FDA responded that the remaining 10 individuals  were not system administrators who required specialized training.
However, 9 of the remaining 10 individuals had significant security  responsibilities, which included the deputy chief information security  officer and several information systems security officers.
According to FDA staff, the agency is currently developing role-based  training courses for executives and contracting officer’s representatives,  and will update its IT administrator module on or around October 1, 2016.  Until FDA implements procedures that provide reasonable assurance that  it tracks and provides role-based training to employees with significant  information security responsibilities, the agency will have less assurance  that staff have the adequate knowledge, skills, and abilities consistent  with their roles to protect the confidentiality, integrity, and availability of  the information.

			FDA Did Not Fully Test Controls or Monitor Them Effectively

A key element of an information security program is to test and evaluate  policies, procedures, and controls to determine whether they are effective  and operating as intended. This type of oversight is a fundamental  element because it demonstrates management’s commitment to the  security program, reminds employees of their roles and responsibilities,  and identifies areas of noncompliance and ineffectiveness. FISMA  requires that the frequency of tests and evaluations of management,  operational, and technical controls be based on risks and occur no less  than annually. OMB directs agencies to meet their FISMA-required  controls testing by drawing on security control assessment results that  include, but are not limited to, continuous monitoring activities. OMB also  requires agencies to develop and maintain an information system  continuous monitoring (ISCM) strategy and implement an ISCM program  in accordance with NIST guidelines. OMB required agencies to develop  their ISCM strategies by February 28, 2014.
Continuous monitoring of security controls employed within or inherited by  the system is an important aspect of managing risk to information from  the operation and use of information systems. The objective of continuous  monitoring is to determine if the set of deployed security controls  continues to be effective over time in light of the inevitable changes that  occur to a system and within an agency. Such monitoring is intended to  assist in maintaining an ongoing awareness of information security,  vulnerabilities, and threats to support agency risk management decisions.  The monitoring of security controls using automated support tools can  help facilitate continuous monitoring.
FDA has taken steps to monitor security controls through bi-weekly  vulnerability scanning using automated tools. The agency also conducted  annual assessments of its information systems. However, the agency did  not fully or annually assess controls for 2 of the 7 systems we reviewed.  To illustrate, FDA did not assess any of the security controls for a system  supporting its scientific research activities. For the other system, which  supports FDA’s IT infrastructure, the agency had not conducted an  assessment since 2013, thus not meeting FISMA’s requirement to assess  controls at least annually. Further, we found that FDA has not developed  and documented a continuous monitoring strategy for its information  systems. HHS’s inspector general previously reported this weakness in  fiscal years 2013 and 2014.
According to FDA staff, the agency plans to assess the infrastructure  system during fiscal year 2016 since the system was being restructured  during fiscal year 2015. In addition, the agency plans to implement a pilot  program for continuous monitoring in August 2016. Further, the agency  plans to implement the Department of Homeland Security’s Continuous  Diagnostics and Mitigation tool in 2016 to improve continuous monitoring  of its IT assets. Until it fully tests controls for all systems and develops  and documents a continuous monitoring strategy, FDA has less  assurance that controls over its information and information systems are  in place and operating as intended.

			Identified Security Weaknesses Were Not Always Remedied in a Timely Fashion or Based on Risk

FISMA requires that agency-wide information security programs include a  process for planning, implementing, evaluating, and documenting  remedial actions to address any deficiencies in the information security  policies, procedures, and practices of the agency. Agencies should  establish procedures to reasonably ensure that all information security  control weaknesses, regardless of how or by whom they are identified,  are addressed through the agency’s remediation processes. For each  identified control weakness, the agency is to develop and implement a  plan of actions and milestones (POA&M) based on findings from security  control assessments, security impact analyses, continuous monitoring of  activities, audit reports, and other sources. When considering appropriate  corrective actions to be taken, the agency should, to the extent possible,  consider the potential agency-wide implications and design appropriate  corrective actions to systemically address the deficiency.
FDA’s Plans of Action and Milestones Guide is generally consistent with  federal guidance, and the agency’s guide specifically requires that high- risk weaknesses be corrected within 60 days.
FDA had also generally developed and documented POA&Ms for  addressing security control weaknesses and made efforts to consider  agency-wide implications of security weaknesses. However, it did not  always complete remedial actions in a timely manner in accordance with  the agency’s established deadlines or risk requirements. To illustrate, for  the seven major applications and general support systems we examined,  183 of 611 (roughly 30 percent) of the POA&Ms had not been remedied  by their scheduled completion date, 30 of which were identified as high  risk and not corrected within the agency-defined requirement of 60 days.  Of the 183 delayed POA&Ms, 102 had a scheduled completion date of  2013 or earlier. As a further example, FDA’s remedial action plans listed  two high-risk weaknesses identified by its Office of Inspector General in  2006 and 2007, but FDA had not mitigated these weaknesses even  though the agency had planned completion dates in 2012.
FDA personnel stated that they faced challenges in remediating POA&Ms  in a timely manner and based on risk. According to FDA personnel, there  was a large volume of open POA&Ms and insufficient resources, which  delayed addressing weaknesses in a timely manner: as of the first quarter  of 2015, FDA had 1,265 open POA&Ms. FDA staff also noted that risk is  considered in prioritizing remediation, but that other factors such as  available resources and business impacts are also considered. FDA  personnel stated that, because of the large number of open POA&Ms,  they will go after “low-hanging fruit,” favoring remediation of a larger  number of POA&Ms over concentrating on high-risk weaknesses.
By not resolving identified weaknesses in a timely manner, or in  accordance with its own policy, FDA faces an increased likelihood that  weaknesses, including high-risk vulnerabilities, will go uncorrected, be  exploited, and result in greater harm to agency systems and information.

			FDA Did Not Fully Implement Elements of Its Incident Response Program

Even with strong information security controls, incidents can still occur.  Agencies can reduce the risks associated with these events by detecting  and promptly responding before significant damage is done. A key  element of an effective incident response program includes implementing  comprehensive policies, procedures, and controls in order to rapidly  detect incidents, minimize loss and destruction, mitigate the weaknesses  that were exploited, and restore computing services. NIST SP 800-53  recommends that agencies review and update their incident response  policy and procedures at an organization-defined frequency. NIST also  recommends that an organization coordinate its incident handling  activities with contingency planning activities so that during a severe  incident, the agency has actions in place to keep its business operational.  NIST further recommends that agencies implement lessons learned from  ongoing incident handling activities into incident response procedures,  training, and testing, and implements the resulting changes accordingly.
While FDA has developed and documented an incident response policy,  the agency did not comply with its own policy of updating its incident  response policy every 3 years. The policy has not been updated since it  was created in January 2007.
Further, neither FDA’s incident response policy nor its procedures require  or describe steps for coordinating incident response activities with  planning for contingencies or system disruptions. The agency also did not  update its incident response procedures using the results of lessons  learned from prior incident response table top exercises we examined.  For example, results from a 2012 table top exercise indicated that FDA  should better train its employees so that newer, less-experienced staff are  better able to respond to significant cyber incidents, and that FDA should  update its procedures to include training requirements. However, the  lessons learned were not incorporated into FDA’s incident response  procedures. Without effective incident response practices in place, FDA  has reduced assurance that its systems and information are protected  and that it can respond to incidents.
In response to our findings, FDA staff mentioned that the agency is in the  process of incorporating lessons learned from incident handling activities  into its incident response procedures, training, and testing. In addition, the  agency stated that it is taking various steps to address incident response  based on our feedback from previous surveys and data requests. The  agency stated that it has discontinued its incident response standard  operating procedure and was developing a new one based on NIST SP  800-61. The agency’s staff also mentioned that personnel will undergo  security training and that FDA is piloting various products to improve the  agency’s overall security posture, including incident response. We have  not yet verified that the agency has implemented these actions, but such  actions could improve FDA’s incident response capability.

	Conclusions

Although FDA has implemented numerous controls and taken steps  intended to protect its information and information systems, pervasive  control weaknesses continue to jeopardize the confidentiality, integrity,  and availability of its sensitive information. In fiscal year 2015, the agency  centralized the management and location of its network and security  operations with intended goals that include establishing real-time network  awareness and improved incident detection. The agency also  immediately resolved some of the weaknesses we identified during this  review. Nonetheless, significant weaknesses in controls for preventing or  limiting unauthorized access to its systems and information, as well as  weaknesses in other controls, such as those for ensuring that software  and hardware are updated and securely configured and that sensitive  media is disposed of, put FDA’s systems at risk. This is significant  considering that these systems handle proprietary business data from  companies in multiple industries and sensitive public health data.
An underlying cause for many of these weaknesses is that FDA has not  fully implemented its agency-wide information security program, such as  developing and documenting appropriate policies and procedures,  ensuring security controls are tested effectively, remediating weaknesses  in a timely manner, and planning for contingencies or system disruptions  and effectively managing risks. The widespread weaknesses in technical  controls and the incomplete implementation of program elements suggest  that the agency has not made effective information security a high  enough priority. Until FDA implements these practices and controls, it will  have limited assurance that its information and information systems are  adequately protected against unauthorized access, disclosure,  modification, or loss.

	Recommendations for Executive Action

To effectively implement key elements of the Food and Drug  Administration’s (FDA) information security program, we are  recommending that the Secretary of Health and Human Services direct  the Commissioner of FDA to implement the following 15  recommendations:  1.  Complete a risk assessment and authorization to operate for one FDA  system.  2.  Ensure that completed risk assessments for six systems reviewed  address the likelihood and impact of threats to FDA.  3.  Develop a policy for system maintenance.  4.  Develop procedures for the following 8 security control families: Audit  and Accountability, Identification and Authentication, Maintenance,  Media Protection, Physical and Environmental Protection, Security  Planning, Systems Communication and Protection, and System  Information and Integrity.  5.  Enhance procedures for the following 7 security control families:  Access Control, Awareness and Training, Security Assessment and  Authorization, Configuration Management, Program Management,  Personnel Security, and System and Services Acquisition.  6.  Review and update as needed per FDA’s frequency, the policies for  the following 11 security control families: Access Control, Audit and  Accountability, Contingency Planning, Identification and  Authentication, Incident Response, Media Protection, Physical and  Environmental Protection, Security Planning, Personnel Security,  System and Services Acquisition, and System and Information  Integrity.  7.  Develop and document a security plan for one system supporting  FDA’s scientific research.  8.  Update security plans to ensure the plans fully and accurately  document the controls selected and intended for protecting each of  the six systems.  9.  Review and approve security plans for the six systems reviewed at  least annually.  10. Implement a process to effectively monitor and track training for  personnel with significant security roles and responsibilities.  11. Ensure that personnel with significant security responsibilities receive  role-based training.  12. Test controls at least annually for the two systems that support FDA’s  scientific research and IT infrastructure.  13. Implement remedial actions in accordance with FDA’s prescribed time  frames or update milestones if actions are delayed.  14. Update FDA’s incident response policy in accordance with agency  requirements.  15. Update incident response procedures to include (1) instructions for  coordinating incident response with contingency planning and (2)  lessons learned from incident response tests.
We are also making 166 technical recommendations in a separate report  with limited distribution. These recommendations address information  security weaknesses related to boundary protection, identification and  authentication, authorization, cryptography, physical security,  configuration management, and media protection.

	Agency Comments and Our Evaluation

We received written comments on a draft of this report from the  Department of Health and Human Services (HHS). In the comments  (reprinted in appendix II), the department stated that FDA concurred with  our recommendations, has begun implementing several of them, and is  actively working to address all the recommendations as quickly and  completely as possible. The department also stated that FDA has  acquired third-party expertise to assist in these efforts to immediately  address the recommendations in our report.
The department emphasized its commitment to protecting the public  health and proprietary business information at FDA, including by  implementing layered defenses and other compensating controls. HHS  further noted that FDA has not experienced a major cybersecurity-related  breach that exposed industry or public health information and that  information security remains a high priority at FDA. The department  added that since hiring its CIO in 2015, FDA has undertaken steps to  better ensure the prevention, detection, and correction of incidents. These  include the development of an IT strategic plan and the restructuring of  cybersecurity leadership, among other initiatives.
In addition, HHS noted that we did not identify an elevated risk of  exposure and/or exfiltration of trade secret and/or other sensitive  information. However, this does not accurately reflect the results of our  review. As stated in the report, we identified a significant number of  weaknesses in technical controls—including access controls, change  controls, and patch management—that jeopardize the confidentiality,  integrity, and availability of the seven moderate- and high-impact systems  we reviewed. Moreover, several of these weaknesses affected FDA’s  general support systems, which are connected to numerous systems  beyond the ones we reviewed. As previously mentioned, these  weaknesses place the seven FDA systems, including those that receive,  process, and maintain sensitive industry and public health data, at  increased and unnecessary risk of unauthorized access, use, or  modification.
The department also made additional comments regarding our report and  methodology. In particular, it stated that our methodology did not use an  industry-standard approach to assessing risk, defined as the likelihood of  a given threat source exploiting a particular vulnerability and the resulting  significance of the impact of that adverse event on the organization, or  quantify this risk in our overall assessment. We did not perform a  comprehensive risk assessment of FDA’s information systems and  information because that is FDA’s responsibility, not ours. However, we  did consider the elements of risk to agency systems and information  during our review. For example, as stated in the report, in selecting the  seven systems we reviewed, we considered FDA’s categorization of the  impact or magnitude of harm to the agency’s operations, assets, and  individuals should the confidentiality, integrity, or availability of the  systems and the information they contain be compromised. Six of the  seven systems we selected were assigned a Federal Information  Processing Standard rating of moderate or high impact by FDA, indicating  that the loss of confidentiality, integrity, or availability of these systems or  the information they contain would have either a serious or  severe/catastrophic impact on the organization. We also considered how  each control weakness, vulnerability, or program shortcoming we  identified could impair or diminish the effectiveness of a security control or  be exploited to facilitate unauthorized system activity. Our report identifies  numerous weaknesses and vulnerabilities along with their potential  impact if the vulnerabilities are exploited. It is also noteworthy that our  work determined that for the reviewed systems, FDA had not determined  the likelihood and impact of threats to those systems.
HHS also stated that our report did not consider other FDA tools,  resources, and capabilities designed to prevent, detect, and correct  incidents, such as its ability to prevent or mitigate breaches like the one  that occurred in October 2013. We recognize that FDA has implemented  numerous security controls and key elements of its information security  program; however, the weaknesses we identified nevertheless pose  increased and unnecessary risk to its systems and information. For  example, as noted in our report, FDA had not updated its incident  response policy since 2007 or incorporated other key elements. Having a  complete and up-to-date incident response capability is essential to  ensuring that FDA staff have the knowledge and tools to effectively  respond to security incidents, such as breaches.
Finally, the department stated that our report does not consistently or  clearly distinguish which of the systems reviewed contained sensitive  information and which do not. It noted, for example, that FDA’s Scientific  Network is a research and development network that does not contain  trade secret information. However, as we noted in our report, FDA’s  systems operate in an interconnected and networked environment, and  the agency had not ensured that the Scientific Network, for example, was  adequately isolated from other systems containing sensitive data, nor had  it developed and implemented risk management controls for this system.  These weaknesses could provide an attacker with a pathway from this  less-secure system to other systems containing sensitive public health or  proprietary business data. Such weaknesses therefore pose an increased  risk to the sensitive information FDA collects and maintains.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to relevant congressional  committees, the Secretary of Health and Human Services, the  Commissioner of FDA, and other interested parties. In addition, the report  will be available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report please contact  Gregory C. Wilshusen at (202) 512-6244 or wilshuseng@gao.gov or Dr.  Nabajyoti Barkakati at (202) 512-4499 or barkakatin@gao.gov. Contact  points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this report. GAO staff who made key  contributions to this report are listed in appendix III.

Appendix I: Objective, Scope, and Methodology

The objective of our review was to evaluate the extent to which the Food  and Drug Administration (FDA) has implemented information security  controls to effectively protect the confidentiality, integrity, and availability  of its information on selected information systems.
To determine the effectiveness of the FDA’s security controls, we gained  an understanding of the overall network environment, identified  interconnectivity and control points, and examined controls for the  agency’s networks and facilities. We reviewed controls over the network  infrastructure and selected systems that processed confidential  commercial and proprietary business information. We performed our work  at FDA headquarters in Silver Spring, Maryland, and at several data  centers in Ashburn, Virginia, and Silver Spring, Maryland.
We selected a non-generalizable sample of seven systems for review  that (1) receive, transmit, and/or process sensitive drug information; (2)  are essential to FDA’s mission, support its business processes, and  contain or process sensitive proprietary business information; and (3)  were assigned a Federal Information Processing Standard rating of  moderate or high impact. These systems perform the following support  functions:
Support and facilitate post-market product safety surveillance of  human drugs, biologics, devices, and combination products. Provide a  data repository for collecting, storing, viewing, analyzing, reporting,  and tracking the receipt of adverse event data or medication errors.
Establish a single gateway or communications portal for accepting  electronic submissions or allowing authorized users to view or obtain  information. Examples of electronic submissions include industry- provided trade secrets, adverse event records, and a multitude of  different records related to FDA’s regulatory oversight of regulated  products.
Provide capabilities for regulatory scientific research, while also  supporting FDA’s overall goals and objectives in areas where  information technology requires supercomputer-strength  computational power.
Support FDA’s research and development activities.
Provide a platform through which FDA organizations may disseminate  FDA-related information to interested parties, including the public,  health professionals, regulated industries, and the media. Provide  information about the various product areas that FDA regulates (food,  drugs, medical devices, cosmetics, etc.), timely advisories (e.g.,  anticipated disease outbreaks such as the Severe Acute Respiratory  Syndrome (SARS), buying medicines online, and LASIK surgery), and  other FDA activities. Provide links to related reference materials and  opportunities for consumers and industry to interact with the FDA.
Provide basic network and security capabilities for the FDA enterprise.
Facilitate receipt and review of electronic drug applications, to include  scans and checks of the validity of drug submissions from industry  and making them available for reviewers, as well as providing file  shares for storing successful submissions that are to be reviewed  To evaluate FDA’s controls over its information systems, we used our  Federal Information System Controls Audit Manual, which contains  guidance for reviewing information system controls that affect the  confidentiality, integrity, and availability of computerized information;  National Institute of Standards and Technology (NIST) standards and  guidelines; Department of Health and Human Services guidelines; FDA  policies and procedures; and standards and guidelines from relevant  security and IT security organizations, such as the National Security  Agency and the Center for Internet Security, and the Interagency Security  Committee.  reviewed firewall configurations, among other things, to determine  whether system boundaries had been adequately protected;  reviewed the complexity and expiration of password settings to  determine if password management was being enforced; analyzed administrative users’ system access permissions to  determine whether their authorizations exceeded that necessary to  perform their assigned duties; observed configurations for providing secure data transmissions  across the network to determine whether sensitive data were being  encrypted;  reviewed software security settings to determine if modifications of  sensitive or critical system resources had been monitored and logged; observed physical access controls to determine if computer facilities  and resources were being protected from espionage, sabotage,  damage, and theft; examined configuration settings and access controls for routers,  network management servers, switches, and firewalls;  inspected key servers and workstations to determine if critical patches  had been installed and/or were up-to-date; examined contingency plans for seven systems to determine whether  those plans had been developed and tested;  reviewed media handling procedures to determine if equipment used  for clearing sensitive data had been tested to ensure correct  performance; and  reviewed personnel clearance procedures to determine whether staff  had been properly cleared prior to gaining access to sensitive  information or information systems.
Using the requirements identified by the Federal Information Security  Modernization Act of 2014 (FISMA), which establishes key elements for  an effective agency-wide information security program, and associated  NIST guidelines, Department of Health and Human Services and Food  and Drug Administration Requirements, we evaluated FDA’s information  security program by  reviewing assessments of risk for six FDA systems to determine  whether threats and vulnerabilities were being identified; analyzing FDA policies, procedures, and practices to determine their  effectiveness in providing guidance to personnel responsible for  securing information and information systems; analyzing security plans for six systems to determine if those plans  had been documented and updated according to federal guidance; examining the security awareness training for employees and  contractors to determine whether they had received training according  to federal requirements; examining training records for personnel who have significant  responsibilities to determine whether they had received training  commensurate with those responsibilities; analyzing FDA’s procedures and results for testing and evaluating  security controls to determine whether management, operational, and  technical controls for seven systems had been sufficiently tested at  least annually and based on risk;  reviewing FDA’s implementation of continuous monitoring practices to  determine whether the agency had developed and implemented an  information system continuous monitoring strategy to manage its IT  assets and monitor the security configurations and vulnerabilities for  those assets; examining FDA’s process to correct weaknesses and to determine  whether remedial action plans complied with federal guidance; and  reviewing FDA’s implementation of incident response practices.
To determine the reliability of FDA’s computer-processed data, we  evaluated the materiality of the data to our audit objective and assessed  the data by various means, including reviewing related documents,  interviewing knowledgeable agency officials, and reviewing internal  controls. Through a combination of methods, we concluded that the data  were sufficiently reliable for the purposes of our work.
We conducted this performance audit from February 2015 to August 2016  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objective.

Appendix II: Comments from the Department of Health and Human Services

Appendix III: GAO Contacts and Staff Acknowledgments

	GAO Contacts

	Staff Acknowledgments

In addition to the individuals named above, Gary Austin, West Coile, Larry  Crosland, and Chris Warweg (Assistant Directors); Vernetta Marquis  (Analyst in Charge); Alexander Anderegg, Angela Bell, Saar Dagani,  Angel Ip, Lee McCracken, Constantine Papanastasiou, Dwayne Staten,  and Michael Stevens made key contributions to this report.

Output:
Why GAO Did This Study

FDA has a demanding responsibility of ensuring the safety, effectiveness, and quality of food, drugs, and other consumer products. In carrying out its mission, FDA relies extensively on information technology systems to receive, process, and maintain sensitive industry and public health data, including proprietary business information such as industry drug submissions and reports of adverse reactions. Accordingly, effective information security controls are essential to ensure that the agency's systems and information are adequately protected from inadvertent or deliberate misuse, improper modification, unauthorized disclosure, or destruction.
GAO was asked to examine security controls over key FDA information systems. GAO assessed the extent to which FDA had effectively implemented information security controls to protect the confidentiality, integrity, and availability of its information on seven information systems selected for review. To do this, GAO reviewed security policies, procedures, reports, and other documents; examined the agency's network infrastructure; tested controls for the seven systems; and interviewed FDA personnel.

What GAO Found

Although the Food and Drug Administration (FDA), an agency of the Department of Health and Human Services (HHS), has taken steps to safeguard the seven systems GAO reviewed, a significant number of security control weaknesses jeopardize the confidentiality, integrity, and availability of its information and systems. The agency did not fully or consistently implement access controls, which are intended to prevent, limit, and detect unauthorized access to computing resources. Specifically, FDA did not always (1) adequately protect the boundaries of its network, (2) consistently identify and authenticate system users, (3) limit users' access to only what was required to perform their duties, (4) encrypt sensitive data, (5) consistently audit and monitor system activity, and (6) conduct physical security reviews of its facilities. FDA conducted background investigations for personnel in sensitive positions, but weaknesses existed in other controls, such as those intended to manage the configurations of security features on and control changes to hardware and software; plan for contingencies, including systems disruptions and their recovery; and protect media such as tapes, disks, and hard drives to ensure information on them was “sanitized” and could not be retrieved after they are disposed of. The table below shows the number of GAO-identified weaknesses and associated recommendations, by control area.
These control weaknesses existed, in part, because FDA had not fully implemented an agency-wide information security program, as required under the Federal Information Security Modernization Act of 2014 and the Federal Information Security Management Act of 2002. For example, FDA did not
ensure risk assessments for reviewed systems were comprehensive and addressed system threats,
review or update security policies and procedures in a timely manner,
complete system security plans for all reviewed systems or review them to ensure that the appropriate controls were selected,
ensure that personnel with significant security responsibilities received training or that such training was effectively tracked,
always test security controls effectively and at least annually,
always ensure that identified security weaknesses were addressed in a timely manner, and
fully implement procedures for responding to security incidents.
Until FDA rectifies these weaknesses, the public health and proprietary business information it maintains in these seven systems will remain at an elevated and unnecessary risk of unauthorized access, use, disclosure, alteration, and loss.

What GAO Recommends

GAO is making 15 recommendations to FDA to fully implement its agency-wide information security program. In a separate report with limited distribution, GAO is recommending that FDA take 166 specific actions to resolve weaknesses in information security controls. HHS stated in comments on a draft of this report that FDA concurred with GAO's recommendations and has begun implementing several of them.