The Phoenix Cardiac Surgery medical practice was handed a $100,000 fine for failing to protect patient information. The resulting resolution agreement from the Office of Civil Rights (OCR) is very interesting. Let’s take a look at is.
The full resolution agreement can be found here (PDF).
Lack of training for employees
(a) From April 14, 2003 to October 21, 2009, Covered Entity did not provide and document training of each workforce member on required policies and procedures with respect to PHI as necessary and appropriate for each workforce member to carry out his/her function within the Covered Entity.
Lack of HIPAA Privacy Policies and Procedures
(b) From September 1, 2005 until November 1, 2009, Covered Entity failed to have in place appropriate and reasonable administrative and technical safeguards to protect the privacy of protected health information (PHI). These failures contributed to and are evidenced by the following acts or omissions:
(i) From July 3, 2007 until February 6, 2009, Covered Entity posted over 1,000 separate entries of ePHI on a publicly accessible, Internet-based calendar; and
(ii) From September 1, 2005 until November 1, 2009, Covered Entity daily transmitted ePHI from an Internet-based email account to workforce members’ personal Internet-based email accounts
Lack of HIPAA Security Policies and Procedures
(c) From September 1, 2005 until November 30, 2009, Covered entity did not implement required administrative and technical security safeguards for the protection of ePHI. These failures contributed to and are evidenced by the following acts or omissions:
(i) From September 1, 2005 (when Covered Entity began sending ePHI by email) until April 16, 2009, Covered Entity failed to identify a security official; and
(ii) From September 1, 2005 (when Covered Entity began sending ePHI by email) until November 30, 2009, Covered Entity failed to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity and availability of the ePHI held by the covered entity.
Lack of Business Associate Agreements
(d) From September 1, 2005 until December 3, 2009, Covered Entity failed to obtain satisfactory assurances in business associates agreements from the Internet-based calendar and from the Internet-based public email providers that these entities would appropriately safeguard the ePHI received from Covered Entity. This failure is evidenced by the following acts and omissions:
(i) From September 1, 2005 until November 1, 2009, Covered Entity permitted the entity providing the Internet-based email account to receive, store, maintain and transmit ePHI on the Covered Entity’s Page 3 behalf without obtaining satisfactory assurances in a business associate agreement with the entity; and
(ii) From July 3, 2007 until December 3, 2009, Covered Entity permitted the entity providing the Internet-based calendar application to receive, store, and maintain ePHI on its behalf without obtaining satisfactory assurances in a business associate agreement with the entity.
Terms and Conditions of penalty
6. Payment. The Covered Entity agrees to pay OCR the amount of $100,000.00 (Resolution Amount). The Covered Entity agrees to pay the Resolution Amount by (1) certified check made payable to “United States Department of Health and Human Services”; or (2) electronic funds transfer pursuant to written instructions to be provided by OCR. The Covered Entity agrees to make this payment on or before the date it signs this Agreement.
Corrective Action Plan
The Corrective Action Plan includes the following:
- Create Policies and Procedures within 60 days. Policies and Procedures should include a Risk Assessment, Risk Management plan to reduce risks, appoint a HIPAA security officer, implement Business Associate Agreements, etc. Policies and Procedures to be approved by OCR
- Distribute Policies and Procedures within 30 days after approval by OCR
- Train all employees on Policies and Procedures within 60 days and new employees within 15 days
- Provide OCR with any Reportable Events or security breaches within 60 days
It is important to understand what OCR is requiring of Phoenix Cardiac Surgery so you can ensure that your organization has all of these security measures in place BEFORE any audit.