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HHS Is Serious About Privacy and Security!

HHS is Serious About Privacy & Security

HHS is serious about privacy and security! Last week, HHS again demonstrated this on January 2, 2013, when HHS announced the first HIPAA breach settlement involving less than 500 patients. The provider, Hospice of North Idaho, (HONI) settled with HHS for $50,000.

This is the first settlement involving a breach of unprotected electronic protected health information (ePHI) affecting fewer than 500 individuals.

The HHS Office for Civil Rights (OCR) began its investigation after HONI reported to HHS that an unencrypted laptop computer containing the electronic protected health information (ePHI) of 441 patients had been stolen in June 2010. Laptops containing ePHI are regularly used by the organization as part of their field work. Over the course of the investigation, OCR discovered that HONI had not conducted a risk analysis to safeguard ePHI. Further, HONI did not have in place policies or procedures to address mobile device security as required by the HIPAA Security Rule. Since the June 2010 theft, HONI has taken extensive additional steps to improve their HIPAA Privacy and Security compliance program.

“This action sends a strong message to the health care industry that, regardless of size, covered entities must take action and will be held accountable for safeguarding their patients’ health information.” said OCR Director Leon Rodriguez. “Encryption is an easy method for making lost information unusable, unreadable and undecipherable.”

HONI entered into a 2 year CAP (corrective action plan) with HHS which included the following findings related that demonstrate that HHS is serious about privacy and security

  1. HONI did not conduct an accurate and thorough analysis of the risk to the confidentiality of ePHI on an on-going basis as part of its security management process from the compliance date of the Security Rule to January 17, 2012. In particular, HONI did not evaluate the likelihood and impact of potential risks to the confidentiality of electronic PHI maintained in and transmitted using portable devices, implement appropriate security measures to address such potential risks, document the chosen security measures and the rationale for adopting those measures, and maintain on an on-going basis reasonable and appropriate security measures.
  2. HONI did not adequately adopt or implement security measures sufficient to ensure the confidentiality of ePHI that it created, maintained, and transmitted using portable devices to a reasonable and appropriate level from the compliance date of the Security Rule to May 1, 2011
  3. HONI was required to designate an authorized representative to be the point of contact with HHS throughout the 2 year corrective action plan.
  4. HONI has to report to HHS any violations of its Privacy and Security policies and detail remedial actions they have taken to respond to the violation.
  5. Any further HIPAA violations can result in additional civil money penalties.

The Resolution Agreement can be found here.

You should know that the Health Information Technology for Economic and Clinical Health (HITECH) Breach Notification Rule requires covered entities to report an impermissible use or disclosure of protected health information, or a “breach,” of 500 individuals or more to the Secretary of HHS and the media within 60 days after the discovery of the breach. Smaller breaches affecting less than 500 individuals must be reported to the Secretary on an annual basis.

So many problems can be averted through diligent and consistent usage of encryption and common-sense measures that staff may use when traveling with computers and other mobile devices.

HHS is serious about Privacy and Security.  You and your practice should be too.


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