Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a settlement with Comprehensive Neurology, PC (Comprehensive), a small New York neurology practice, concerning a potential violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule. The settlement resolves an OCR investigation of a ransomware attack against Comprehensive.
The settlement resolves OCR’s investigation of a ransomware attack against Comprehensive. In December 2020, OCR received a breach report from Comprehensive that stated that its IT network, including all of its ePHI, had been encrypted and rendered inaccessible by ransomware. Comprehensive determined that 6,800 individuals may have been affected. The compromised ePHI included patient names, clinical information, health insurance information, demographic information, Social Security numbers, as well as driver’s license and state identification numbers. OCR’s investigation found that Comprehensive failed to conduct an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the confidentiality, integrity, and availability of the ePHI held by Comprehensive.
Under the terms of the settlement, Comprehensive agreed to implement a corrective action plan that will be monitored by OCR for two years and paid $25,000 to OCR. Under the corrective action plan, Comprehensive will be required to take specific steps toward resolving potential violations of the HIPAA Security Rule, including:
- Conducting an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the ePHI in its information systems;
- Developing and implementing a risk management plan to address and mitigate security risks and vulnerabilities identified in the risk analysis;
- Reviewing, and to the extent necessary, revising its written policies and procedures to comply with the HIPAA Rules; and
- Training its workforce 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/sites/default/files/ocr-hipaa-racap-np.pdf, opens in a new tab [PDF, 245 KB]
Source: HHS