How many data breaches can an entity have before either some regulator steps in with a corrective action plan or something happens to reduce the likelihood of more breaches? Consider the following:
Breach # 1
On February 22, 2022, Minuteman Senior Services (MSS) identified suspicious activity related to an employee’s email account. According to the notification the non-profit organization sent in June 2022, their investigation determined an employee’s email account was accessed by an unknown actor for a limited time between February 22, 2022 and February 23, 2022. A total of 213 people were affected by the February 2022 incident.
Breach #2
On June 1, 2022, MSS identified suspicious activity related to an employee’s email account. According to their substitute notice of July 29, 2022, their investigation determined that an employee email account was accessible by an unknown individual for less than 24 hours on June 1, 2022, but:
The investigation was unable, however, to determine exactly which email messages or attachments may have been accessed or viewed. In an abundance of caution, we conducted a comprehensive review of the information stored within the email account at the time of the event to determine what information was contained within the account and to whom the information related. Once complete, we also worked to validate the results and locate appropriate contact information.
On July 29, 2022, MSS notified HHS that 4,000 patients were affected.
On October 30, 2024 — more than two years later — MSS provided an update that it was continuing to mail notifications to individuals affected by this incident.
Breach #3
On November 30, 2022, MSS identified suspicious activity related to an employee’s email account. A substitute notice on their website stated that their investigation showed that unauthorized access had occurred between November 21 and November 30.
When MSS reported the incident to HHS on January 23, 2023, they reported it with a “500” marker for the number of patients affected. At that time, individual letters had not yet gone out to those affected.
On February 27, 2024 — more than one year later — MSS updated its webpage on the November 2022 incident. Their update included the following statement:
Unfortunately, the investigation was unable to determine exactly which email messages or attachments may have been accessed or viewed. In an abundance of caution, a detailed and thorough programmatic and manual review of the contents of the email account was performed to determine whether sensitive information was contained with the account. This exhaustive review involved the manual assessment of thousands of documents. This was a time-intensive process, as we worked to understand to whom the information belonged and obtain the most up-to-date address information for notifications. This process was recently completed.
The types of information that may have been present in the impacted email account during the event could have included full name, address, Social Security number, date of birth, diagnosis and treatment information, health insurance information, patient identification number, provider name, prescription information, and Medicare/Medicaid information.
MSS’s January 2023 report to HSS on this incident has not been updated. It still shows the “500” marker.
HHS Investigations Are Still Open?
Because the February 2022 incident reportedly affected less than 500 patients, it does not show up on HHS’s public breach tool, but the June 2022 and November 2022 incidents do show up, and there is no closing statement by HHS for either of them.
Is HHS actively investigating MSS’s compliance with the HIPAA Security Rule? Given that MSS had three breaches in less than one year and all involved employee email accounts, doesn’t that seem to call for a somewhat prioritized response to help this non-profit comply and better protect patient data?