Privileged Access Management (PAM) Policy (AC-POL-004)

1. Objective

The objective of this policy is to establish comprehensive controls for managing privileged accounts and administrative access within [Company Name]’s information systems and infrastructure. This policy ensures that accounts with elevated privileges are subject to enhanced security controls, monitoring, and governance to protect the confidentiality, integrity, and availability of critical systems and electronic Protected Health Information (ePHI). This policy implements just-in-time access principles, enhanced authentication requirements, and comprehensive monitoring to minimize the risk associated with privileged account compromise.

2. Scope

This policy applies to all [Company Name] workforce members, contractors, and third parties who require elevated administrative privileges to perform their job functions. It encompasses all privileged accounts including system administrators, database administrators, cloud administrators, network administrators, security administrators, and service accounts with elevated privileges. This policy covers all systems and platforms including on-premises infrastructure, cloud services, applications, databases, network devices, and security tools. It applies to all environments (production, staging, development, testing) where privileged access is required.

3. Policy

Privileged accounts and administrative access shall be managed through rigorous controls that implement just-in-time access principles, enhanced authentication, comprehensive monitoring, and strict approval processes to minimize security risks.

3.1 Principles of Privileged Access Management

Privileged access management shall be based on fundamental security principles that minimize risk and ensure accountability.

3.1.1 Least Privilege and Separation of Duties

3.1.1.1 Minimal Privilege Assignment

Privileged accounts shall be granted only the minimum level of access necessary to perform specific administrative functions. Broad administrative privileges shall be avoided in favor of granular, function-specific permissions.

3.1.1.2 Role-Based Privilege Assignment

Privileged access shall be assigned based on clearly defined administrative roles with documented responsibilities and access requirements. Role definitions shall be regularly reviewed and updated to reflect current business needs.

3.1.1.3 Separation of Duties

Critical administrative functions shall be divided among multiple individuals to prevent single points of failure and reduce the risk of unauthorized actions. No single individual shall have complete administrative control over critical systems.

3.1.1.4 Temporary Privilege Elevation

Standard user accounts shall be used for routine activities, with privilege elevation requested only when administrative functions are required. Permanent assignment of elevated privileges shall be minimized.

3.1.2 Enhanced Authentication and Authorization

3.1.2.1 Multi-Factor Authentication Requirements

All privileged accounts shall require multi-factor authentication using approved authentication methods. Hardware tokens or biometric authentication may be required for critical infrastructure access.

3.1.2.2 Privileged Access Workstation Requirements

Dedicated secured workstations shall be used for privileged access to critical systems, isolated from general-purpose computing activities.

3.1.2.3 Network-Based Access Controls

Privileged access shall be restricted to authorized networks and locations, with additional controls for remote privileged access.

3.2 Just-in-Time (JIT) Access Implementation

Privileged access shall be granted on a time-limited, just-in-time basis to minimize exposure and reduce the attack surface of elevated privileges.

3.2.1 Time-Limited Access Sessions

3.2.1.1 Session Duration Limits

Critical Infrastructure Access (production databases, cloud administrative consoles) shall have a maximum session duration of [Duration, e.g., 4 hours] with automatic termination. Standard Administrative Access (system administration, application management) shall have a maximum session duration of [Duration, e.g., 8 hours] with renewal available. Development and Testing Access shall have a maximum session duration of [Duration, e.g., 24 hours] with self-service renewal.

3.2.1.2 Automatic Session Termination

Privileged access sessions shall automatically terminate upon expiration, with no automatic renewal. Users shall request new access through established approval processes.

3.2.1.3 Emergency Access Procedures

Break-glass access procedures shall be established for emergency situations, with enhanced monitoring and immediate notification requirements.

3.2.2 Dynamic Access Approval

3.2.2.1 Request-Based Access

Privileged access shall be requested through automated workflows with business justification and approval requirements. Standing privileged access shall be minimized.

3.2.2.2 Approval Workflows

Access requests shall require approval from appropriate managers and security personnel based on the risk level and scope of requested privileges.

3.2.2.3 Access Reviews

All active privileged access shall be reviewed at least quarterly to ensure continued business justification and appropriate usage. Privileged access review cadence is authoritative in this policy; standard (non-privileged) access review cadence is defined in AC-POL-001 (annual).

3.3 Privileged Account Provisioning and Management

Comprehensive processes shall govern the creation, modification, and termination of privileged accounts throughout their lifecycle.

3.3.1 Privileged Account Management Implementation

Privileged Account Provisioning and Approval:
- Privileged account requests shall be submitted through [Access Management System] with business justification, required access level, and duration specification
- Hiring managers shall review and approve privileged account requests confirming business need and appropriate access level for role responsibilities
- Information Security Officer shall conduct risk assessment for privileged account requests evaluating access scope, duration, and potential security impact
- Privileged accounts shall be created with minimum necessary permissions and configured with multi-factor authentication requirements
- All privileged accounts shall be enrolled in Privileged Access Management (PAM) system with session recording and access approval workflows
Privileged Account Security Controls:
- Account owners shall complete privileged account security training within [Duration, e.g., 5 business days] of account creation
- PAM system shall require approval for each privileged session through [Approval Process, e.g., manager approval, security team approval]
- All privileged account usage shall be monitored in real-time by the Security Operations Center with investigation of suspicious activities within [Duration, e.g., 15 minutes]
- PAM system shall record all privileged sessions including keystrokes, commands, and file access for audit and investigation purposes
- Emergency access accounts and break-glass procedures shall be implemented with enhanced monitoring and immediate notification requirements
Privileged Account Monitoring and Reporting:
- Quarterly privileged account usage reports and attestation reviews shall be generated and documented, including login times, commands executed, and systems accessed
- Quarterly privileged account activity summaries shall be reviewed by the Information Security Officer to investigate any anomalous or unauthorized usage patterns
- Monthly reviews of assigned privileged accounts shall be conducted by account managers to verify continued business need and appropriate access levels
- Real-time monitoring shall include detection of privileged access anomalies, unusual command execution, and potential abuse patterns
- Integration with SIEM systems shall provide comprehensive visibility into privileged account activities across all systems and platforms
Privileged Account Lifecycle Management:
- Quarterly comprehensive review of all privileged accounts shall be performed including access validation, usage analysis, and compliance assessment
- Privileged account passwords shall be rotated quarterly using [Password Management System] with [Complexity Requirements, e.g., 20+ characters]
- Annual privileged access risk assessment shall be conducted with updates to access controls based on threat landscape and business requirements
- Privileged account deprovisioning shall include secure deletion of recorded sessions and access logs according to retention policies

3.4 Session Monitoring and Recording

Comprehensive monitoring and recording of privileged access sessions shall provide accountability and forensic capabilities.

3.4.1 Real-Time Session Monitoring

3.4.1.1 Continuous Monitoring

All privileged access sessions shall be monitored in real-time by security personnel or automated systems. Suspicious activities shall trigger immediate alerts and investigation.

3.4.1.2 Behavioral Analysis

User behavior analytics shall identify anomalous privileged access patterns, unusual command execution, or potential insider threats.

3.4.1.3 Geographic and Time-Based Monitoring

Privileged access from unusual locations or outside normal business hours shall trigger enhanced monitoring and approval requirements.

3.4.2 Session Recording and Audit

3.4.2.1 Comprehensive Session Recording

All privileged access sessions shall be recorded including keystrokes, commands, screen activity, and file access for audit and forensic purposes.

3.4.2.2 Audit Trail Maintenance

Complete audit trails shall be maintained for all privileged account activities with secure storage and tamper-evident controls.

3.4.2.3 Forensic Capabilities

Session recordings and audit logs shall provide sufficient detail for incident investigation and forensic analysis.

3.5 Separated Administrative Accounts

Administrative functions shall be performed using dedicated accounts separate from standard user accounts to limit exposure and improve security.

3.5.1 Account Separation Requirements

3.5.1.1 Dedicated Administrative Accounts

Workforce members with administrative privileges shall use separate, dedicated accounts for administrative functions. These accounts shall not be used for general productivity tasks.

3.5.1.2 Standard Account Usage

Routine business activities including email, web browsing, and document creation shall be performed using standard, non-privileged user accounts.

3.5.1.3 Account Naming Conventions

Administrative accounts shall follow standardized naming conventions to clearly identify their privileged nature and associated user.

3.5.2 Administrative Account Security

3.5.2.1 Enhanced Security Controls

Administrative accounts shall be subject to additional security controls including stronger authentication requirements, network access restrictions, and enhanced monitoring.

3.5.2.2 Limited Network Access

Administrative accounts shall only be permitted to access systems and networks necessary for their administrative functions.

3.5.2.3 Regular Security Assessments

Administrative accounts shall undergo regular security assessments to validate proper configuration and usage.

3.6 Emergency Access and Break-Glass Procedures

Emergency access procedures shall provide rapid access to critical systems during security incidents or business emergencies while maintaining security controls.

3.6.1 Emergency Access Procedures

3.6.1.1 Break-Glass Account Management

Emergency access accounts shall be maintained for critical systems with enhanced monitoring and immediate notification when accessed.

3.6.1.2 Emergency Approval Process

Emergency access shall require approval from designated emergency responders and security personnel, with justification documented.

3.6.1.3 Post-Emergency Review

All emergency access usage shall be reviewed within [Duration, e.g., 24 hours] to validate appropriateness and document lessons learned.

3.6.2 Emergency Access Monitoring

3.6.2.1 Immediate Notification

Emergency access activation shall trigger immediate notifications to security personnel, management, and relevant stakeholders.

3.6.2.2 Enhanced Logging

All emergency access activities shall be subject to enhanced logging and monitoring with detailed audit trails.

3.6.2.3 Incident Response Integration

Emergency access procedures shall be integrated with incident response processes to ensure coordinated response activities.

4. Standards Compliance

This policy is designed to comply with and support the following industry standards and regulations.

Policy Section	Standard/Framework	Control Reference
All	HITRUST CSF v11.2.0	11.a - Access Control Policy
3.2, 3.3	HITRUST CSF v11.2.0	11.b - User Access Management
3.3.1	HITRUST CSF v11.2.0	11.a - User Access Provisioning
3.3.1	HITRUST CSF v11.2.0	11.b - Privileged Access Management
3.3.1	HITRUST CSF v11.2.0	11.c - User Access Review
3.3.1	HITRUST CSF v11.2.0	11.d - User Access Revocation
3.4	HITRUST CSF v11.2.0	12.a - Audit Logging and Monitoring
3.1, 3.5	HITRUST CSF v11.2.0	11.c - User Responsibilities
All	HIPAA Security Rule	45 CFR § 164.308(a)(4) - Information Access Management
3.3.1	HIPAA Security Rule	45 CFR § 164.308(a)(4) - Access Management
3.4	HIPAA Security Rule	45 CFR § 164.312(b) - Audit Controls
All	SOC 2 Trust Services Criteria	CC6.1 - Logical Access Security
3.3.1	SOC 2 Trust Services Criteria	CC6.2 - Logical Access Controls
3.1, 3.4	SOC 2 Trust Services Criteria	CC6.3 - Multi-Factor Authentication
3.4	SOC 2 Trust Services Criteria	CC7.2 - System Monitoring

5. Definitions

Break-Glass Access: Emergency access procedure that provides rapid access to critical systems during emergencies with enhanced monitoring and approval requirements.
Just-in-Time (JIT) Access: Security approach that provides privileged access only when needed and for limited time periods to minimize exposure.
Privileged Access Management (PAM): Comprehensive approach to controlling, monitoring, and managing privileged accounts and administrative access.
Privileged Access Workstation (PAW): Dedicated, hardened workstation used exclusively for privileged administrative functions.
Privileged Account: User account with elevated permissions beyond those of standard users, typically used for administrative functions.
Session Recording: Comprehensive recording of privileged access sessions including keystrokes, commands, and screen activity for audit purposes.

6. Responsibilities

Role	Responsibility
Security Officer	Develop privileged access policies, oversee PAM program implementation, approve high-risk privileged access requests, and conduct quarterly privileged access assessments.
Information Security Team	Monitor privileged access activities, investigate security alerts, maintain PAM systems, and provide security guidance for privileged access requirements.
System Administrators	Create and manage privileged accounts, configure PAM systems, generate usage reports, rotate passwords according to schedule, and ensure compliance with privileged access controls.
Managers	Approve privileged access requests for their team members, conduct quarterly reviews of assigned privileged accounts, verify continued business need for privileged access, and ensure team compliance with privileged access policies.
Human Resources	Immediately notify IT and Security teams of employee terminations and role changes affecting privileged access, maintain accurate role information for privileged access management.
Compliance Officer	Maintain audit logs and session recordings for regulatory compliance, document privileged access procedures for audit purposes, and ensure retention requirements are met.
Privileged Users	Use privileged accounts only for authorized administrative functions, complete required security training, report suspected privileged account compromise, and comply with session monitoring requirements.
All Workforce Members	Report suspicious privileged access activities, protect privileged account credentials, and support privileged access security initiatives.