Tag Archives: OCR

OCR Sets HIPPA Enforcement Record with Cottage Health Settlement

OCR Sets HIPPA Enforcement Record with Cottage Health Settlement

California-based Cottage Health agreed to pay $3 million and implement a corrective action plan as part of a HIPAA settlement to resolve allegations it had unintentionally disclosed electronic patient information. This settlement, in December 2018, brought the annual total of collections from OCR enforcement actions to $28.7 million, setting a new annual record.

Two Breaches

Cottage Health, which operates four hospitals in California, notified HHS’ OCR about two breaches of unsecured electronic protected health information (ePHI), one in December 2013 and another in December 2015, affecting more than 62,500 individuals.

The first incident occurred when the security configuration settings of the health system’s Windows operating system reportedly permitted access to files containing ePHI without requiring a username and password. As a result, patient information was available to anyone on the internet with access to Cottage Health’s server. Continue reading OCR Sets HIPPA Enforcement Record with Cottage Health Settlement

Florida Contractor Physician Group Pays $500K in HIPAA Settlement

A Florida-based contractor physician group will pay $500,000 to settle alleged HIPAA violations after data on more than 9,000 patients was posted online.

Advanced Care Hospitalists PL (ACH), which provides internal medicine doctors to hospitals and nursing facilities, has also agreed to a corrective action plan as part of the HIPAA settlement, the Department of Health and Human Services announced.

Alleged HIPAA Violations

Between November 2011 and June 2012, ACH worked with an individual who claimed to be a representative of Doctor’s First Choice Billings Inc. for billing services. This person provided services to ACH using First Choice’s website and its branding but operated without knowledge of the Florida-based company’s owner, according to HHS.  Continue reading Florida Contractor Physician Group Pays $500K in HIPAA Settlement

OCR Announces Six-Figure HIPAA Settlement

The U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) announced a $125,000 settlement with Allergy Associates of Hartford, P.C., a three-physician allergy practice in Connecticut, for HIPAA Privacy Rule violations.

Alleged HIPAA Violation

According to OCR’s press release and corrective action plan, a patient of Allergy Associates contacted a reporter about a dispute between the patient and a doctor regarding the patient’s service animal. The reporter contacted the doctor for comment and the doctor was alleged to have impermissibly disclosed the patient’s protected health information to the reporter.

While the allergy practice had HIPAA policies and procedures in place, the physician did not adhere to the policies.  Further, once OCR uncovered the issue, it also found that the practice failed to sanction the physician involved in accordance with its policies. Continue reading OCR Announces Six-Figure HIPAA Settlement

OCR Releases Improved HIPAA Security Risk Assessment Tool

Under the HIPAA Security Rule, a covered entity or business associate must perform risk assessments to determine the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information. Failing to conduct risk assessments is a common basis for significant fines.

Risk assessments, however, can be a taunting task, particularly for smaller organizations with limited resources. In an effort to help organizations perform risk assessments and comply with the HIPAA Security Rule, the Office of the National Coordinator for Health Information Technology (ONC) and the HHS Office for Civil Rights (OCR) have jointly launched an updated HIPAA Security Risk Assessment (SRA) Tool.

The SRA Tool is designed for small to medium sized health care practices (up to 10 health care providers) and business associates to help them identify ePHI risks and vulnerabilities. Continue reading OCR Releases Improved HIPAA Security Risk Assessment Tool

OCR Issues Guidance for Sharing Medical Information During Hurricane Florence

As Hurricane Florence approaches the North Carolina coastline, OCR has released guidance to ensure that medical information is shared appropriately during the hurricane.

The Secretary of HHS has declared a public health emergency in North Carolina, South Carolina, and Virginia. Under these circumstances, the Secretary has exercised the authority to waive sanctions and penalties against a covered hospital that does not comply with the following provisions of the HIPAA Privacy Rule.

  • The requirement to obtain a patient’s agreement to speak with family members or friends involved in the patient’s care.
  • The requirement to honor a request to opt out of the facility directory.
  • The requirement to distribute a notice of privacy practices.
  • The patient’s right to request privacy restrictions.
  • The patient’s right to request confidential communications.

Continue reading OCR Issues Guidance for Sharing Medical Information During Hurricane Florence

Guidance on Disposing Sensitive Data-Storing Devices

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) recently released their July 2018 newsletter entitled: Guidance on Disposing of Electronic Devices and Media(Guidance) , which provides suggestions for properly disposing technology that may contain sensitive data – such as financial or protected health information (PHI). While directly applicable to the healthcare sector, this guidance is best practice for all organizations.

OCR’s Mission

Part of OCR’s mission is to provide guidance to health care providers, insurers and other stakeholders on cybersecurity issues like properly disposing equipment that contains sensitive information. This equipment includes desktops, laptops, tablets, copiers, servers, smartphones, hard drives, USB drives and other type of electronic storage devices.

Improper disposal of devices can lead to a data breach that can be costly to an organization, both financially and reputationally. Some of the financial costs include notifications, investigations, lawsuits, consultants, legal counsel, fees paid to security specialists and loss of clients. Continue reading Guidance on Disposing Sensitive Data-Storing Devices

OCR Announces Fourth Largest Penalty Ever

The U.S. Department of Health and Human Services, Office for Civil Rights (OCR) recently announced an Administrative Law Judge (ALJ) ruled against The University of Texas MD Anderson Cancer Center (MD Anderson) after MD Anderson suffered three breaches that disclosed the health records of about 35,000 patients. The ruling requires MD Anderson to pay $4,348,000 in civil money penalties making it the fourth largest monetary penalty in OCR’s history.

The Three Breaches

MD Anderson suffered three different data breaches in 2012 and 2013. The breaches involved the theft of an unencrypted laptop and the loss of two USB thumb drives containing the unencrypted protected health information of over 33,500 patients.

Lack of Encryption

OCR’s investigation found MD Anderson had written encryption policies dating back to 2006 but those policies were not adopted until 2011 and, even then, MD Anderson did not encrypt all of its electronic devices as evidenced by the breaches in 2012 and 2013.  Furthermore, MD Anderson’s own risk analyses recognized that the lack of device-level encryption posed a high risk to the security of ePHI. Continue reading OCR Announces Fourth Largest Penalty Ever

Key Takeaways from the New and Improved HIPAA Breach Reporting Tool

Several issues were raised in the past about the Office for Civil Rights’ (OCR) website commonly referred to as the “Wall of Shame.” In response, OCR announced the updated version of their rebranded HIPAA Breach Reporting Tool (HBRT).

The old Wall of Shame and new HIPAA Breach Reporting Tool both publish information received from OCR on reported breaches affecting 500+ individuals. However, the Wall of Shame carried an undeserving negative connotation when organizations were publicly and indefinitely listed on the website.

HIPAA Breach Reporting Tool

OCR noted in their announcement, “The HBRT provides transparency to the public and organizations covered by HIPAA and helps highlight the importance of safeguards to protect the privacy and security of sensitive health care information.”

Information posted on the site includes:

  1. Name of the reporting entity
  2. Number of individuals affected by the data breach
  3. Type of data breach (e.g. hacking/IT incident, unauthorized access, etc.)
  4. Location of the breached information (e.g. laptop, paper records, etc.)

Features of the updated HBRT include:

  • Enhanced functionality that highlights breaches currently under investigation and reported within the last 24 months
  • New breach archive that includes information about how breaches were resolved
  • Improved navigation to additional breach information
  • Tips for consumers

OCR plans to continue expanding and improving the website’s features and functionality based on industry feedback.

Healthcare Breach Trends

The HIPAA Breach Reporting Tool recently recorded a new milestone: The OCR has surpassed 2,000 breaches reported affecting 500+ individuals since the HBRT’s inception in September 2009.

There has also been a recent shift in the types of breaches reported. We are seeing a departure from the issue of lost or stolen unencrypted devices containing protected health information. According to the HBRT, the last 24 months have seen a rapid increase in hacking/IT incidents.

The big takeaway: Phishing is a tried and true way to gain access to healthcare facilities.

OCR Calls for More Phishing Awareness

To address phishing, OCR placed emphasis on the importance of phishing awareness in its latest cybersecurity newsletter update.

The OCR newsletter article points to a KPMG study that documents an increase in HIPAA violations and cybersecurity attacks impacting PHI over the past two years. The call to action is training the workforce to detect and properly respond to cyber-attacks and phishing scams.

OCR states, “Training on data security for workforce members is not only essential for protecting an organization against cyber-attacks, it is also required by the HIPAA Security Rule.”

There are several key factors healthcare organizations should consider regarding their approach to data security training:

Frequency of training and updates:

    • How often to train workforce members on security issues
    • How often to send security updates to their workforce members

Relevant and emerging threats:

    • Communicate new and emerging cybersecurity threats to workforce members, such as new social engineering tricks and malware or ransomware variants

Training format:

    • What type of training to provide to workforce members on security issues
    • i.e. computer-based, classroom, monthly newsletters, posters, email alerts, etc.

Training Documentation:

    • How to document training to workforce members, including dates and types of training, training materials, and evidence of participation

Data Security Training Courses

Your organization likely has access to our collection of data security training courses as part of your cyber insurance policy.

The data security training courses provide organizations with training materials for the workforce in several key areas: Introduction to data breaches, Data security basics, Social engineering & Phishing, Safeguarding information, and HIPAA Privacy & Security Rules.

One important aspect of the training courses is the documentation features. The learning management system in place allows your organization to leverage training reports once workforce members have completed the assigned training courses.

OCR notes the importance of documentation in the newsletter, “Any investigator or auditor will ask for documentation, as required by the HIPAA Rules, to ensure compliance with the requirements of the Rules.”

To learn more about how you can leverage the data security training courses in your organization, reach out to our team at cyberteam@eplaceinc.com.

OCR Publishes New Cybersecurity Materials & Guidance

The Office for Civil Rights (OCR) released new guidance materials that should prove helpful for smaller organizations working on a limited budget. The purpose of the new guidance is to help Covered Entities and Business Associates understand the steps involved with responding to a security incident.

Response Checklist

OCR’s checklist is titled ‘My entity just experienced a cyber-attack! What do we do now?’ and briefly touches on several quick-response steps:

  • Execute the response and mitigation procedures and contingency plans
  • Report the crime to applicable law enforcement agencies
  • Report all cyber threat indicators to federal and information-sharing and analysis organizations
  • Report the breach to OCR as soon as possible (but no later than 60 days after discovery of a breach affecting 500 or more individuals)

The accompanying infographic helps to illustrate these steps.

Key Takeaways

Being prepared for a cybersecurity incident and having the response process thought out is a key focus area for our clients. For organizations in the healthcare industry, we have provided foundational templates for building incident response programs. Whether your organization is starting from scratch or just wanted to supplement existing incident response plans, these templates are key resources.

Each of these steps mentioned by the OCR is an important component of an effective incident response plan. You can view our incident response materials through the website in our newsletter. Submit any incident response questions to cyberteam@eplaceinc.com.

Mishandling HIV Information Costs Hospital $387,000

St. Luke’s hospital came under fire after faxing two patients’ sensitive medical information against their request.

The Office for Civil Rights (OCR) reached a settlement with St. Luke’s-Roosevelt Hospital Center over violations of HIPAA’s Privacy Rule related to impermissible disclosure of protected health information (PHI).

Who is St. Luke’s?

According to the OCR press release, St. Luke’s-Roosevelt Hospital Cetner Inc. (St. Luke’s) operates the Institute for Advanced Medicine, formerly Spencer Cox Center for Health, which provides comprehensive health services to persons living with HIV or AIDS and other chronic diseases. St. Luke’s is 1 of 7 hospitals that comprise the Mount Sinai Health System.

Data Breach Details

OCR received an initial complaint in 2014 regarding impermissible disclosure of patient health information by the staff at Spencer Cox Center.

OCR launched an investigation, finding the Spencer Cox Center staff faxed the patient’s PHI directly to his employer, and not his personal post office box as he requested.

Information disclosed included highly sensitive medical information: HIV status, medical care, sexually transmitted diseases, medications, sexual orientation, mental health diagnosis, and physical abuse.

Through the OCR investigation of this event, they discovered Spencer Cox Center was also responsible for a related breach of sensitive information and took no action to address the apparent issue. In the related breach nine months prior, staff faxed PHI of another patient (against their expressed instructions) to an office where the patient volunteered.

Settlement Details

The settlement includes a $387,000 penalty for St. Luke’s, along with a corrective action plan.

The corrective action plan includes several remediation steps:

  • Revise and distribute written policies and procedures concerning the uses and disclosures of PHI (mail, fax, or email), and update them annually
  • Revise and distribute training materials to include instruction on safeguarding PHI

Key Takeaways

For a case that involves the PHI of only two individual patients, this might seem like a heavy assessment by OCR. This high settlement amount conveys OCR’s focus on two areas in this case: 1) penalty proportionate to sensitivity of information and 2) penalty for avoidance of addressing compliance issues.

The settlement amount clearly reflects the sensitive nature of the patient’s information disclosed. The high penalty also addresses the avoidance of initial vulnerabilities. Had the Spencer Cox Center addressed issues within their compliance program during the initial breach, the procedures and policies would be in place to mitigate future events and prevent these types of impermissible disclosure.

It is no surprise to see OCR targeting a case with minimal individuals impacted. OCR noted last year they would start focusing more on smaller breaches. With this example, we see that OCR has been true to their word. We also reported on a $2.4 million penalty earlier in May for an incident involving only one patient’s information.