Enhancing Cyber Resilience: Insights from the CISA Healthcare and Public Health Sector Risk and Vulnerability Assessment

SUMMARY

In January 2023, the Cybersecurity and Infrastructure Security Agency (CISA) conducted a Risk and Vulnerability Assessment (RVA) at the request of a Healthcare and Public Health (HPH) sector organization to identify vulnerabilities and areas for improvement. An RVA is a two-week penetration test of an entire organization, with one week spent on external testing and one week spent assessing the internal network. As part of the RVA, the CISA assessment team conducted web application, phishing, penetration, database, and wireless assessments. The assessed organization was a large organization deploying on-premises software.

During the one-week external assessment, the assessment team did not identify any significant or exploitable conditions in externally available systems that may allow a malicious actor to easily obtain initial access to the organization’s network. Furthermore, the assessment team was unable to gain initial access to the assessed organization through phishing. However, during internal penetration testing, the team exploited misconfigurations, weak passwords, and other issues through multiple attack paths to compromise the organization’s domain.

In coordination with the assessed organization, CISA is releasing this Cybersecurity Advisory (CSA) detailing the RVA team’s activities and key findings to provide network defenders and software manufacturers recommendations for improving their organizations’ and customers’ cyber posture, which reduces the impact of follow-on activity after initial access. CISA encourages the HPH sector and other critical infrastructure organizations deploying on-premises software, as well as software manufacturers, to apply the recommendations in the Mitigations section of this CSA to harden networks against malicious activity and to reduce the likelihood of domain compromise.

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TECHNICAL DETAILS

Note: This advisory uses the MITRE ATT&CK for Enterprise framework, version 14. See the MITRE ATT&CK Tactics and Techniques section for tables of the threat actors’ activity mapped to MITRE ATT&CK^® tactics and techniques with corresponding mitigation and/or detection recommendations. For assistance with mapping malicious cyber activity to the MITRE ATT&CK framework, see CISA and MITRE ATT&CK’s Best Practices for MITRE ATT&CK Mapping and CISA’s Decider Tool.

Introduction

CISA has authority to, upon request, provide analyses, expertise, and other technical assistance to critical infrastructure owners and operators and provide operational and timely technical assistance to federal and non-federal entities with respect to cybersecurity risks. See generally 6 U.S.C. §§ 652(c)(5), 659(c)(6). After receiving a request for an RVA from the organization and coordinating high-level details of the engagement with certain personnel at the organization, CISA conducted the RVA in January 2023.

During RVAs, CISA tests the security posture of an organization’s network over a two-week period to determine the risk, vulnerability, and exploitability of systems and networks. During the first week (the external phase), the team tests public facing systems to identify exploitable vulnerabilities. During the second week (the internal phase), the team determines the susceptibility of the environment to an actor with internal access (e.g., malicious cyber actor or insider threat). The assessment team offers five services:

• Web Application Assessment: The assessment team uses commercial and open source tools to identify vulnerabilities in public-facing and internal web applications, demonstrating how they could be exploited.
• Phishing Assessment: The assessment team tests the susceptibility of staff and infrastructure to phishing attacks and determines what impact a phished user workstation could have on the internal network. The RVA team crafts compelling email pretexts and generates payloads, similar to ones used by threat actors, in order to provide a realistic threat perspective to the organization.
• Penetration Testing: The assessment team tests the security of an environment by simulating scenarios an advanced cyber actor may attempt. The team’s goals are to establish a foothold, escalate privileges, and compromise the domain. The RVA team leverages both open source and commercial tools for host discovery, port and service mapping, vulnerability discovery and analysis, and vulnerability exploitation.
• Database Assessment: The assessment team uses commercial database tools to review databases for misconfigurations and missing patches.
• Wireless Assessment: The assessment team uses specialized wireless hardware to assess wireless access points, connected endpoints, and user awareness for vulnerabilities.

The assessed organization was in the HPH sector. See Table 1 for services in-scope for this RVA.

Phase I: External Assessment

Penetration and Web Application Testing

The CISA team did not identify any significant or exploitable conditions from penetration or web application testing that may allow a malicious actor to easily obtain initial access to the organization’s network.

Phishing Assessment

The CISA team conducted phishing assessments that included both user and systems testing.

The team’s phishing assessment was unsuccessful because the organization’s defensive tools blocked the execution of the team’s payloads. The payload testing resulted in most of the team’s payloads being blocked by host-based protections through a combination of browser, policy, and antivirus software. Some of the payloads were successfully downloaded to disk without being immediately removed, but upon execution, the antivirus software detected the malicious code and blocked it from running. Some payloads appeared to successfully evade host-based protections but did not create a connection to the command and control (C2) infrastructure, indicating they may have been incompatible with the system or blocked by border protections.

Since none of the payloads successfully connected to the assessment team’s C2 server, the team conducted a credential harvesting phishing campaign. Users were prompted to follow a malicious link within a phishing email under the pretext of verifying tax information and were then taken to a fake login form.

While twelve unique users from the organization submitted credentials through the malicious form, the CISA team was unable to leverage the credentials because they had limited access to external-facing resources. Additionally, the organization had multi-factor authentication (MFA) implemented for cloud accounts. Note: At the time of the assessment, the CISA team’s operating procedures did not include certain machine-in-the-middle attacks that could have circumvented the form of MFA in place. However, it is important to note that tools like Evilginx[1] can be leveraged to bypass non-phishing resistant forms of MFA. Furthermore, if a user executes a malicious file, opening a connection to a malicious actor’s command and control server, MFA will not prevent the actor from executing commands and carrying out actions under the context of that user.

Phase II: Internal Assessment

Database, Web Application, and Wireless Testing

The CISA assessment team did not identify any significant or exploitable conditions from database or wireless testing that may allow a malicious actor to easily compromise the confidentiality, integrity, and availability of the tested environment.

The team did identify default credentials [T1078.001] for multiple web interfaces during web application testing and used default printer credentials while penetration testing. (See the Attack Path 2 section for more information.)

Penetration Testing

The assessment team starts internal penetration testing with a connection to the organization’s network but without a valid domain account. The team’s goal is to compromise the domain by gaining domain admin or enterprise administrator-level permissions. Generally, the team first attempts to gain domain user access and then escalate privileges until the domain is compromised. This process is called the “attack path”—acquiring initial access to an organization and escalating privileges until the domain is compromised and/or vital assets for the organization are accessed. The attack path requires specialized expertise and is realistic to what adversaries may do in an environment.

For this assessment, the team compromised the organization’s domain through four unique attack paths, and in a fifth attack path the team obtained access to sensitive information.

See the sections below for a description of the team’s attack paths mapped to the MITRE ATT&CK for Enterprise framework. See the Findings section for information on issues that enabled the team to compromise the domain.

Attack Path 1

The assessment team initiated LLMNR/NBT-NS/mDNS/DHCP poisoning [T1557.001] with Responder[2], which works in two steps:

1. Responder listens to multicast name resolution queries (e.g., LLMNR UDP/5355, NBTNS UDP/137) [T1040] and under the right conditions spoofs a response to direct the victim host to a CISA-controlled machine on which Responder is running.
2. Once a victim connects to the machine, Responder exploits the connection to perform malicious functions such as stealing credentials or opening a session on a targeted host [T1021].

With this tool, the CISA team captured fifty-five New Technology Local Area Network Manager version 2 (NTLMv2) hashes, including the NTLMv2 hash for a service account. Note: NTLMv2 and other variations of the hash protocol are used for clients to join a domain, authenticate between Active Directory forests, authenticate between earlier versions of Windows operating systems (OSs), and authenticate computers that are not normally a part of the domain.[3] Cracking these passwords may enable malicious actors to establish a foothold in the domain and move laterally or elevate their privileges if the hash belongs to a privileged account.

The service account had a weak password, allowing the team to quickly crack it [T1110.002] and obtain access to the organization’s domain. With domain access, the CISA assessment team enumerated accounts with a Service Principal Name (SPN) set [T1087.002]. SPN is the unique service identifier used by Kerberos authentication[4], and accounts with SPN are susceptible to Kerberoasting.

The CISA team used Impacket’s[5] GetUserSPNs tool to request Ticket-Granting Service (TGS) tickets for all accounts with SPN set and obtained their Kerberos hashes [T1558.003]. Three of these accounts had domain administrator privileges—offline, the team cracked ACCOUNT 1 (which had a weak password).

Using CrackMapExec[6], the assessment team used ACCOUNT 1 [T1078.002] to successfully connect to a domain controller (DC). The team confirmed they compromised the domain because ACCOUNT 1 had READ,WRITE permissions over the C$ administrative share [T1021.002] (see Figure 1).

To further demonstrate the impact of compromising ACCOUNT 1, the assessment team used it to access a virtual machine interface. If a malicious actor compromised ACCOUNT 1, they could use it to modify, power off [T1529], and/or delete critical virtual machines, including domain controllers and file servers.

Attack Path 2

The team first mapped the network to identify open web ports [T1595.001], and then attempted to access various web interfaces [T1133] with default administrator credentials. The CISA team was able to log into a printer interface with a default password and found the device was configured with domain credentials to allow employees to save scanned documents to a network share [T1080].

While logged into the printer interface as an administrator, the team 1) modified the “Save as file” configuration to use File Transfer Protocol (FTP) instead of Server Message Block (SMB) and 2) changed the Server Name and Network Path to point to a CISA-controlled machine running Responder [T1557]. Then, the team executed a “Connection Test” that sent the username and password over FTP [T1187] to the CISA machine running Responder, which captured cleartext credentials for a non-privileged domain account (ACCOUNT 2).

Using ACCOUNT 2 and Certipy[7], the team enumerated potential certificate template vulnerabilities found in Active Directory Certificate Services (ADCS). Note: ADCS templates are used to build certificates for different types of servers and other entities on an organization’s network. Malicious actors can exploit template misconfigurations [T1649] to manipulate the certificate infrastructure into issuing fraudulent certificates and/or escalate user privileges to a domain administrator.

The WebServer template was misconfigured to allow all authenticated users permission to:

• Change the properties of the template (via Object Control Permissions with Write Property Principals set to Authenticated Users).
• Enroll for the certificate (via Enrollment Permissions including the Authenticated Users group).
• Request a certificate for a different user (via EnrolleeSuppliesSubject set as True).

See Figure 2 for the displayed certificate template misconfigurations.

The template’s Client Authentication was set to False, preventing the CISA assessment team from requesting a certificate that could be used to authenticate to a server in the domain. To demonstrate how this misconfiguration could lead to privilege escalation, the assessment team, leveraging its status as a mere authenticated user, briefly changed the WebServer template properties to set Client Authentication to True so that a certificate could be obtained for server authentication, ensuring the property was set back to its original setting of False immediately thereafter.

The team used Certipy with the ACCOUNT 2 credentials to request a certificate for a Domain Administrator account (ACCOUNT 3). The team then authenticated to the domain controller as ACCOUNT 3 with the generated certificate [T1550] and retrieved the NTLM hash for ACCOUNT 3 [T1003]. The team used the hash to authenticate to the domain controller [T1550.002] and validated Domain Administrator privileges, demonstrating compromise of the domain via the WebServer template misconfiguration.

Attack Path 3

The CISA team used a tool called CrackMapExec to spray easily guessable passwords [T1110.003] across all domain accounts and obtained two sets of valid credentials for standard domain user accounts.

The assessment team leveraged one of the domain user accounts (ACCOUNT 4) to enumerate ADCS via Certipy and found that web enrollment was enabled (see Figure 3). If web enrollment is enabled, malicious actors can abuse certain services and/or misconfigurations in the environment to coerce a server to authenticate to an actor-controlled computer, which can relay the authentication to the ADCS web enrollment service and obtain a certificate for the server’s account (known as a relay attack).

The team used PetitPotam [8] with ACCOUNT 4 credentials to force the organization’s domain controller to authenticate to the CISA-operated machine and then used Certipy to relay the coerced authentication attempt to the ADCS web enrollment service to receive a valid certificate for ACCOUNT 5, the domain controller machine account. They used this certificate to acquire a TGT [T1558] for ACCOUNT 5.

With the TGT for ACCOUNT 5, the CISA team used DCSync to dump the NTLM hash [T1003.006] for ACCOUNT 3 (a Domain Administrator account [see Attack Path 2 section]), effectively leading to domain compromise.

Attack Path 4

The CISA team identified several systems on the organization’s network that do not enforce SMB signing. The team exploited this misconfiguration to obtain cleartext credentials for two domain administrator accounts.

First, the team used Responder to capture the NTLMv2 hash for a domain administrator account. Next, they used Impacket’s NTLMrelayx tool[9] to relay the authentication for the domain administrator, opening a SOCKS connection on a host that did not enforce SMB signing. The team then used DonPAPI[10] to dump cleartext credentials through the SOCKS connection and obtained credentials for two additional domain administrator accounts.

The CISA team validated the privileges of these accounts by checking for READ,WRITE access on a domain controller C$ share [T1039], demonstrating Domain Administrator access and therefore domain compromise.

Attack Path 5

The team did vulnerability scanning [T1046] and identified a server vulnerable to CVE-2017-0144 (an Improper Input Validation [CWE-20] vulnerability known as “EternalBlue” that affects SMB version 1 [SMBv1] and enables remote code execution [see Figure 4]).

The CISA assessment team then executed a well-known EternalBlue exploit [T1210] and established a shell on the server. This shell allowed them to execute commands [T1059.003] under the context of the local SYSTEM account.

With this local SYSTEM account, CISA dumped password hashes from a Security Account Manager (SAM) database [T1003.002]. The team parsed the hashes and identified one for a local administrator account. Upon parsing the contents of the SAM database dump, the CISA team identified an NTLM hash for the local administrator account, which can be used to authenticate to various services.

The team sprayed the acquired NTLM hash across a network segment and identified multiple instances of password reuse allowing the team to access various resources including sensitive information with the hash.

Findings

Key Issues

The CISA assessments team identified several findings as potentially exploitable vulnerabilities that could compromise the confidentiality, integrity, and availability of the tested environment. Each finding, listed below, includes a description with supporting details. See the Mitigations section for recommendations on how to mitigate these issues.

The CISA team rated their findings on a severity scale from critical to informational (see Table 2).

The CISA assessment team identified four High severity vulnerabilities and one Medium severity vulnerability during penetration testing that contributed to the team’s ability to compromise the domain. See Table 3 for a list and description of these findings.

In addition to the issues listed above, the team identified three High and seven Medium severity findings. These vulnerabilities and misconfigurations may allow a malicious actor to compromise the confidentiality, integrity, and availability of the tested environment. See Table 4 for a list and description of these findings.

Additional Issues

The CISA team identified one Informational severity within the organization’s networks and systems. These issues may allow a malicious actor to compromise the confidentiality, integrity, and availability of the tested environment, but are not readily exploitable. The information provided is to encourage the stakeholder to investigate these issues further to adjust their environments or eliminate certain aspects as needed, but the urgency is low.

Noted Strengths

The CISA team noted the following business, technical, and administrative components that enhanced the network security posture of the tested environment:

• The organization’s network was found to have several strong, security-oriented characteristics such as:
  • Effective antivirus software;
  • Endpoint detection and response capabilities;
  • Good policies and best practices for protecting users from malicious files including not allowing users to mount ISO files;
  • Minimal external attack surface, limiting an adversary’s ability to leverage external vulnerabilities to gain initial access to the organization’s networks and systems;
  • Strong wireless protocols;
  • And network segmentation.
• The organization’s security also demonstrated their ability to detect some of the CISA team's actions throughout testing and overall situational awareness through the use of logs and alerts.
• The organization used MFA for cloud accounts. The assessment team obtained cloud credentials via a phishing campaign but was unable to use them because of MFA prompts.

MITIGATIONS

Network Defenders

CISA recommends HPH Sector and other critical infrastructure organizations implement the mitigations in Table 6 to mitigate the issues listed in the Findings section of this advisory. These mitigations align with the Cross-Sector Cybersecurity Performance Goals (CPGs) developed by CISA and the National Institute of Standards and Technology (NIST). The CPGs provide a minimum set of practices and protections that CISA and NIST recommend all organizations implement. CISA and NIST based the CPGs on existing cybersecurity frameworks and guidance to protect against the most common and impactful threats, tactics, techniques, and procedures. Visit CISA’s Cross-Sector Cybersecurity Performance Goals for more information on the CPGs, including additional recommended baseline protections.

Additionally, CISA recommends that HPH sector organizations implement the following strategies to mitigate cyber threats:

• Mitigation Strategy #1 Asset Management and Security:
  • CISA recommends that HPH sector organizations implement and maintain an asset management policy to reduce the risk of exposing vulnerabilities, devices, or services that could be exploited by threat actors to gain unauthorized access, steal sensitive data, or disrupt critical services. The focus areas for this mitigation strategy include asset management and asset security, addressing asset inventory, procurement, decommissioning, and network segmentation as they relate to hardware, software, and data assets.
• Mitigation Strategy #2 Identity Management and Device Security:
  • CISA recommends entities secure their devices and digital accounts and manage their online access to protect sensitive data and PII/PHI from compromise. The focus areas for this mitigation strategy include email security, phising prevention, access management, password policies, data protection and loss prevention, and device logs and monitoring solutions.
• Mitigation Strategy #3 Vulnerability, Patch, and Configuration Management:
  • CISA recommends entities mitigate known vulnerabilities and establish secure configuration baselines to reduce the likelihood of threat actors exploiting known vulnerabilities to breach organizational networks. The focus areas for this mitigation strategy include vulnerability and patch Management, and configuration and change management.

For more information on these mitigations strategies, see CISA’s Healthcare and Public Health Sector webpage.

Software Manufacturers

The above mitigations apply to HPH sector and other critical infrastructure organizations with on-premises or hybrid environments. Recognizing that insecure software is the root cause of the majority of these flaws, and that the responsibility should not be on the end user, CISA urges software manufacturers to implement the following to reduce the prevalence of misconfigurations, weak passwords, and other weaknesses identified and exploited through the assessment team:

• Embed security into product architecture throughout the entire software development lifecycle (SDLC).
• Eliminate default passwords. Do not provide software with default passwords. To eliminate default passwords, require administrators set a “strong” password [CPG 2.B] during installation and configuration.
• Create secure configuration templates. Provide configuration templates with certain safe settings based on an organization’s risk appetite (e.g., low, medium, and high security templates). Support these templates with hardening guides based on the risks the manufacturer has identified. The default configuration should be a secure one, and organizations should need to opt in if they desire a less secure configuration.
• Design products so that the compromise of a single security control does not result in compromise of the entire system. For example, narrowly provision user privileges by default and employ ACLs to reduce the impact of a compromised account. This will make it more difficult for a malicious cyber actor to escalate privileges and move laterally.
• Mandate MFA, ideally phishing-resistant MFA, for privileged users and make MFA a default, rather than opt-in, feature.

These mitigations align with tactics provided in the joint guide Shifting the Balance of Cybersecurity Risk: Principles and Approaches for Secure by Design Software. CISA urges software manufacturers to take ownership of improving the security outcomes of their customers by applying these and other secure by design tactics. By using secure by design tactics, software manufacturers can make their product lines secure “out of the box” without requiring customers to spend additional resources making configuration changes, purchasing security software and logs, monitoring, and making routine updates.

For more information on secure by design, see CISA’s Secure by Design webpage. For more information on common misconfigurations and guidance on reducing their prevalence, see the joint advisory NSA and CISA Red and Blue Teams Share Top Ten Cybersecurity Misconfigurations.

VALIDATE SECURITY CONTROLS

In addition to applying the listed mitigations, CISA recommends exercising, testing, and validating your organization’s security program against the threat behaviors mapped to the MITRE ATT&CK for Enterprise framework in this advisory. CISA recommends testing your existing security controls inventory to assess how they perform against the ATT&CK techniques described in this advisory.

To get started:

1. Select an ATT&CK technique described in this advisory (see Tables 7 – 16).
2. Align your security technologies against the technique.
3. Test your technologies against the technique.
4. Analyze your detection and prevention technologies’ performance.
5. Repeat the process for all security technologies to obtain a set of comprehensive performance data.
6. Tune your security program, including people, processes, and technologies, based on the data generated by this process.

CISA recommends continually testing your security program, at scale, in a production environment to ensure optimal performance against the MITRE ATT&CK techniques identified in this advisory.

RESOURCES

• For consolidated findings from the RVAs by Fiscal Year mapped to MITRE ATT&CK, see CISA’s Risk and Vulnerability Assessments page.
• See joint CSA NSA and CISA Red and Blue Teams Share Top Ten Cybersecurity Misconfigurations for information on the most common cybersecurity misconfigurations in large organizations and TTPs actors use to exploit these misconfigurations.
• See CISA’s Healthcare and Public Health Sector webpage.
• See CISA’s RedEye tool on CISA’s GitHub page. RedEye is an interactive open-source analytic tool used to visualize and report red team command and control activities. See CISA’s RedEye tool overview video for more information.

REFERENCES

[1]   Github | kgretzky / evilginx
[2]   Github | lgandx / Responder
[3]   Network security LAN Manager authentication level - Windows Security | Microsoft Learn
[4]   Service principal names - Win32 apps | Microsoft Learn
[5]   Github | fortra / impacket
6]   Github | byt3bl33d3r / CrackMapExec
[7]   Github | ly4k / Certipy
[8]   Github | topotam / PetitPotam
[9]   Github | fortra / impacket / examples
[10] Github | login-securite / DonPAPI
[11] SP 800-63B, Digital Identity Guidelines: Authentication and Lifecycle Management | CSRC (nist.gov)

APPENDIX: MITRE ATT&CK TACTICS AND TECHNIQUES

VERSION HISTORY

December 14, 2023: Initial version.