Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a settlement with PIH Health, Inc. (PIH), a California health care network, over potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The violations stem from a phishing attack that exposed unsecured electronic protected health information (ePHI), prompting concerns related to the Privacy, Security, and Breach Notification Rules under HIPAA.
OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules (HIPAA Rules), which set forth the requirements that covered entities (health plans, health care clearinghouses, and most health care providers), and business associates must follow to protect the privacy and security of Americans’ protected health information (PHI).
“Hacking is one of the most common types of large breaches reported to OCR every year,” said OCR Acting Director Anthony Archeval. “HIPAA-regulated entities need to be proactive and remedy the deficiencies in their HIPAA compliance programs before those deficiencies result in the impermissible disclosure of patients’ protected health information.”
The settlement resolves an investigation that OCR conducted after receiving a breach report from PIH in January 2020. The breach report stated that in June 2019, a phishing attack compromised forty-five of its employees’ email accounts, resulting in the breach of 189,763 individuals’ unsecured ePHI. PIH reported that the ePHI disclosed in the phishing attack included affected individuals’ names, addresses, dates of birth, driver’s license numbers, Social Security numbers, diagnoses, lab results, medications, treatment and claims information, and financial information.
OCR’s investigation found multiple potential violations of the HIPAA Rules, including:
- Failure to use or disclose protected health information only as permitted or required by the HIPAA Privacy Rule.
- Failure to conduct an accurate and thorough risk analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI held by PIH.
- Failure to notify affected individuals, the HHS Secretary, and the media of a breach of unsecured protected health information within 60 days of its discovery.
Under the terms of the resolution agreement, PIH has agreed to implement a corrective action plan that will be monitored by OCR for two years and paid a $600,000 settlement to OCR. Under the corrective action plan, PIH is obligated to take definitive steps toward resolving potential violations of the HIPAA Rules, including:
- Conducting an accurate and thorough risk analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of its ePHI.
- Developing and implementing a risk management plan to address and mitigate security risks and vulnerabilities identified in its risk analysis.
- Developing, maintaining, and revising, as necessary, its written policies and procedures to comply with the HIPAA Rules.
- Training its workforce members who have access to PHI on its HIPAA policies and procedures.
OCR recommends that health care providers, health plans, clearinghouses, and business associates that are covered by HIPAA implement the following steps to mitigate or prevent cyber-threats:
- Identify where ePHI is located in the organization, including how ePHI enters, flows through, and leaves the organization’s information systems.
- Integrate risk analysis and risk management into the organization’s business processes.
- Ensure that audit controls are in place to record and examine information system activity.
- Implement regular reviews of information system activity.
- Utilize mechanisms to authenticate information to ensure only authorized users are accessing ePHI.
- Encrypt ePHI in transit and at rest to guard against unauthorized access to ePHI when appropriate.
- Incorporate lessons learned from incidents into the organization’s overall security management process.
- Provide workforce members with regular HIPAA training that is specific to the organization and to the workforce members’ respective job duties.
The resolution agreement and corrective action plan may be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/index.html.
Source: HHS