Sentara is comprised of 12 acute care hospitals with more than 300 sites of care throughout Virginia and North Carolina.

In April of 2017, HHS received a complaint alleging that Sentara had sent a bill to an individual containing another patient’s protected health information (PHI). OCR’s investigation determined that Sentara mailed 577 patients’ PHI to wrong addresses that included patient names, account numbers, and dates of services.  Sentara reported this incident as a breach affecting 8 individuals, because Sentara concluded, incorrectly, that unless the disclosure included patient diagnosis, treatment information or other medical information, no reportable breach of PHI had occurred.  Sentara persisted in its refusal to properly report the breach even after being explicitly advised of their duty to do so by OCR. OCR also determined that Sentara failed to have a business associate agreement in place with Sentara Healthcare, an entity that performed business associate services for Sentara.

“HIPAA compliance depends on accurate and timely self-reporting of breaches because patients and the public have a right to know when sensitive information has been exposed.” said Roger Severino, OCR Director.  “When health care providers blatantly fail to report breaches as required by law, they should expect vigorous enforcement action by OCR.”

In addition to the monetary settlement, Sentara will undertake a corrective action plan that includes two years of monitoring. The resolution agreement and corrective action plan may be found at https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/sentara/index.html

 

It Administers hundreds of programs for people who need assistance, including supplemental nutrition benefits and Medicaid. The Department of Aging and Disability Services (DADS), a state agency that administered long-term care services for people who are aging, and for people with intellectual and physical disabilities, was reorganized into TX HHSC in September 2017.

On June 11, 2015, DADS filed a breach report with OCR stating that the electronic protected health information (ePHI) of 6,617 individuals was viewable over the internet, including names, addresses, social security numbers, and treatment information. The breach occurred when an internal application was moved from a private, secure server to a public server and a flaw in the software code allowed access to ePHI without access credentials. OCR’s investigation determined that, in addition to the impermissible disclosure, DADS failed to conduct an enterprise-wide risk analysis, and implement access and audit controls on its information systems and applications as required by the HIPAA Security Rule. Because of inadequate audit controls, DADS was unable to determine how many unauthorized persons accessed individuals’ ePHI.

The Notice of Proposed Determination and Notice of Final Determination may be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/txhhsc/index.html

URMC filed breach reports with OCR in 2013 and 2017 following its discovery that protected health information (PHI) had been impermissibly disclosed through the loss of an unencrypted flash drive and theft of an unencrypted laptop, respectively. OCR’s investigation revealed that URMC failed to conduct an enterprise-wide risk analysis; implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level; utilize device and media controls; and employ a mechanism to encrypt and decrypt electronic protected health information (ePHI) when it was reasonable and appropriate to do so. Of note, in 2010, OCR investigated URMC concerning a similar breach involving a lost unencrypted flash drive and provided technical assistance to URMC. Despite the previous OCR investigation, and URMC’s own identification of a lack of encryption as a high risk to ePHI, URMC permitted the continued use of unencrypted mobile devices.

“Because theft and loss are constant threats, failing to encrypt mobile devices needlessly puts patient health information at risk,” said Roger Severino, OCR Director. “When covered entities are warned of their deficiencies, but fail to fix the problem, they will be held fully responsible for their neglect.”

In addition to the monetary settlement, URMC will undertake a corrective action plan that includes two years of monitoring their compliance with the HIPAA Rules. The resolution agreement and corrective action plan may be found at http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/urmc/index.html.

JHS is a nonprofit academic medical system based in Miami, Florida, which operates six major hospitals, a network of urgent care centers, multiple primary care and specialty care centers, long-term care nursing facilities, and corrections health services clinics. 

On August 22, 2013, JHS submitted a breach report to OCR stating that its Health Information Management Department had lost paper records containing the protected health information (PHI) of 756 patients in January 2013. JHS’s internal investigation determined that an additional three boxes of patient records were also lost in December 2012; however, JHS did not report the additional loss or the increased number of individuals affected to 1,436, until June 7, 2016.

In July 2015, OCR initiated an investigation following a media report that disclosed the PHI of a JHS patient. A reporter had shared a photograph of a JHS operating room screen containing the patient’s medical information on social media. JHS subsequently determined that two employees had accessed this patient’s electronic medical record without a job-related purpose.

On February 19, 2016, JHS submitted a breach report to OCR reporting that an employee had been selling patient PHI. The employee had inappropriately accessed over 24,000 patients’ records since 2011.

OCR’s investigation revealed that JHS failed to provide timely and accurate breach notification to the Secretary of HHS, conduct enterprise-wide risk analyses, manage identified risks to a reasonable and appropriate level, regularly review information system activity records, and restrict authorization of its workforce members’ access to patient ePHI to the minimum necessary to accomplish their job duties.

JHS waived its right to a hearing and did not contest the findings in OCR’s Notice of Proposed Determination. Accordingly, OCR issued a Notice of Final Determination and JHS has paid the full civil money penalty.

“OCR’s investigation revealed a HIPAA compliance program that had been in disarray for a number of years,” said OCR Director Roger Severino. “This hospital system’s compliance program failed to detect and stop an employee who stole and sold thousands of patient records; lost patient files without notifying OCR as required by law; and failed to properly secure PHI that was leaked to the media.”

The Notice of Proposed Determination and Notice of Final Determination may be found at: http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/jackson/index.html.

On June 5, 2016, OCR received a complaint from an Elite patient alleging that Elite had responded to a social media review by disclosing the patient’s last name and details of the patient’s health condition.  OCR’s investigation found that Elite had impermissibly disclosed the protected health information (PHI) of multiple patients in response to patient reviews on the Elite Yelp review page.  Additionally, Elite did not have a policy and procedure regarding disclosures of PHI to ensure that its social media interactions protect the PHI of its patients or a Notice of Privacy Practices that complied with the HIPAA Privacy Rule.  OCR accepted a substantially reduced settlement amount in consideration of Elite’s size, financial circumstances, and cooperation with OCR’s investigation.

“Social media is not the place for providers to discuss a patient’s care,” said OCR Director, Roger Severino.  “Doctors and dentists must think carefully about patient privacy before responding to online reviews.”

In addition to the monetary settlement, Elite will undertake a corrective action plan that includes two years of monitoring by OCR for compliance with the HIPAA Rules. The resolution agreement and corrective action plan may be found at: http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/elite/index.html.