In May 2022, DataBreaches reported that ambulance billing service Comstar LLC in Massachusetts was notifying an undisclosed number of people following a data security breach of their system detected on March 26, 2022.
On May 26, 2022, they also notified HHS of the incident, reporting that 68,957 patients were affected.
Today, HHS OCR announced that OCR had initiated an investigation after receiving Comstar’s report of May 26, 2022. A press release issued today summarizes the concerns:
Comstar did not detect the [March 19] intrusion until March 26, 2022. Ransomware was used to encrypt Comstar’s network servers and the ePHI of approximately 585,621 individuals was affected. At the time of the breach, Comstar was a business associate of over 70 HIPAA covered entities. The type of ePHI impacted was clinical, including medical assessments and medication administration information. OCR’s investigation determined that Comstar failed to conduct an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the ePHI that it holds.
No mention was made of the discrepancy between the number affected [585,621] and the significantly lower number reported by Comstar to HHS in May of 2022 and never updated thereafter, but the covered entities affected may have self-reported to HHS.
Under the terms of the settlement Comstar agreed to implement a corrective action plan that OCR will monitor for two years, and paid OCR $75,000. The corrective action plan requires Comstar to:
- Conduct a comprehensive and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI that Comstar holds;
- Develop a risk management plan to address and mitigate security risks and vulnerabilities identified in the risk analysis;
- Review and revise, as necessary, its written policies and procedures to comply with the HIPAA Privacy, Security, and Breach Notification Rules; and
- Train its workforce members who have access to PHI on its HIPAA policies and procedures.
The resolution agreement and corrective action plan may be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/hhs-hipaa-agreement-comstar/index.html
Today’s announcement was HHS OCR’s 13th ransomware enforcement action and 9th enforcement action in OCR’s Risk Analysis Initiative.