HIPAA Compliance News

December 2021 Healthcare Data Breach Report

56 data breaches of 500 or more healthcare records were reported to the HHS’ Office for Civil Rights (OCR) in December 2021, which is a 17.64% decrease from the previous month. In 2021, an average of 59 data breaches were reported each month and 712 healthcare data breaches were reported between January 1 and December 31, 2021. That sets a new record for healthcare data breaches, exceeding last year’s total by 70 – An 10.9% increase from 2020.

2021 healthcare data breaches

Across December’s 56 data breaches, 2,951,901 records were exposed or impermissibly disclosed – a 24.52% increase from the previous month. At the time of posting, the OCR breach portal shows 45,706,882 healthcare records were breached in 2021 – The second-highest total since OCR started publishing summaries of healthcare data breaches in 2009.

2021 healthcare data breaches - records breached

Largest Healthcare Data Breaches in December 2021

Name of Covered Entity State Covered Entity Type Individuals Affected Breach Cause
Oregon Anesthesiology Group, P.C. OR Healthcare Provider 750,500 Ransomware
Texas ENT Specialists TX Healthcare Provider 535,489 Ransomware
Monongalia Health System, Inc. WV Healthcare Provider 398,164 Business Email Compromise/Phishing
BioPlus Specialty Pharmacy Services, LLC FL Healthcare Provider 350,000 Hacked network server
Florida Digestive Health Specialists, LLP FL Healthcare Provider 212,509 Business Email Compromise/Phishing
Daniel J. Edelman Holdings, Inc. IL Health Plan 184,500 Business associate hacking/IT incident
Southern Orthopaedic Associates d/b/a Orthopaedic Institute of Western Kentucky KY Healthcare Provider 106,910 Compromised email account
Fertility Centers of Illinois, PLLC IL Healthcare Provider 79,943 Hacked network server
Bansley and Kiener, LLP IL Business Associate 50,119 Ransomware
Oregon Eye Specialists OR Healthcare Provider 42,612 Compromised email accounts
MedQuest Pharmacy, Inc. UT Healthcare Provider 39,447 Hacked network server
Welfare, Pension and Annuity Funds of Local No. ONE, I.A.T.S.E. NY Health Plan 20,579 Phishing
Loyola University Medical Center IL Healthcare Provider 16,934 Compromised email account
Bansley and Kiener, LLP IL Business Associate 15,814 Ransomware
HOYA Optical Labs of America, Inc. TX Business Associate 14,099 Hacked network server
Wind River Family and Community Health Care WY Healthcare Provider 12,938 Compromised email account
Ciox Health GA Business Associate 12,493 Compromised email account
A New Leaf, Inc. AZ Healthcare Provider 10,438 Ransomware

Causes of December 2021 Healthcare Data Breaches

18 data breaches of 10,000 or more records were reported in December, with the largest two breaches – two ransomware attacks – resulting in the exposure and potential theft of a total of 1,285,989 records. Ransomware continues to pose a major threat to healthcare organizations. There have been several successful law enforcement takedowns of ransomware gangs in recent months, the most recent of which saw authorities in Russia arrest 14 members of the notorious REvil ransomware operation, but there are still several ransomware gangs targeting the healthcare sector including Mespinoza, which the HHS’ Health Sector Cybersecurity Coordination Center (HC3) issued a warning about this month due to the high risk of attacks.

Phishing attacks continue to result in the exposure of large amounts of healthcare data. In December, email accounts were breached that contained the ePHI of 807,984 individuals. The phishing attack on Monongalia Health System gave unauthorized individuals access to email accounts containing 398,164 records.

8 of the largest breaches of the month involved compromised email accounts, two of which were business email compromise attacks where accounts were accessed through a phishing campaign and then used to send requests for changes to bank account information for upcoming payments.

Causes of December 2021 healthcare data breaches

Throughout 2021, hacking and other IT incidents have dominated the breach reports and December was no different. 82.14% of the breaches reported in December were hacking/IT incidents, and those breaches accounted for 91.84% of the records breached in December – 2,711,080 records. The average breach size was 58,937 records and the median breach size was 4,563 records. The largest hacking incident resulted in the exposure of the protected health information of 750,050 individuals.

The number of unauthorized access and disclosure incidents has been much lower in 2021 than in previous years. In December there were only 5 reported unauthorized access/disclosure incidents involving 234,476 records. The average breach size was 46,895 records and the median breach size was 4,109 records.

There were two reported cases of the loss of paper/films containing the PHI of 3,081 individuals and two cases of theft of paper/films containing the PHI of 2,129 individuals. There was also one breach involving the improper disposal of a portable electronic device containing the ePHI of 934 patients.

As the chart below shows, the most common location of breached PHI was network servers, followed by email accounts.

Location of breached PHUI in December 2021 healthcare data breaches

HIPAA Regulated Entities Reporting Data Breaches in December 2021

Healthcare providers suffered the most data breaches in December, with 36 breaches reported. There were 11 breaches reported by health plans, and 9 breaches reported by business associates. Six breaches were reported by healthcare providers (3) and health plans (3) that occurred at business associates. The adjusted figures are shown in the pie chart below.

December 2021 healthcare data breaches by HIPAA-regulated entity type

December 2021 Healthcare Data Breaches by U.S. State

Illinois was the worst affected state with 11 data breaches, four of which were reported by the accountancy firm Bansley and Kiener and related to the same incident – A ransomware attack that occurred in December 2020. the firm is now facing a lawsuit over the incident and the late notification to affected individuals – 12 months after the attack was discovered.

State Number of Breaches
Illinois 11
Indiana 5
Florida, Oklahoma, and Texas 4
Arizona 3
California, Georgia, Kansas, Michigan, New York, Oregon, Utah, and Virginia 2
Alabama, Colorado, Kentucky, Maryland, North Carolina, Rhode Island, Wisconsin, West Virginia, and Wyoming 1

HIPAA Enforcement Activity in December 2021

There were no further HIPAA penalties imposed by the HHS’ Office for Civil Rights in December. The year closed with a total of 14 financial penalties paid to OCR to resolve violations of the HIPAA Rules. 13 of the cases were settled with OCR, and one civil monetary penalty was imposed. 12 of the OCR enforcement actions were for violations of the HIPAA Right of Access.

The New Jersey Attorney General imposed a $425,000 financial penalty on Regional Cancer Care Associates, which covered three separate Hackensack healthcare providers – Regional Cancer Care Associates LLC, RCCA MSO LLC, and RCCA MD LLC – that operate healthcare facilities in 30 locations in Connecticut, New Jersey, and Maryland.

The New Jersey Attorney General and the New Jersey Division of Consumer Affairs investigated a breach of the email accounts of several employees between April and June 2019 involving the protected health information of 105,000 individuals and a subsequent breach when the breach notification letters were sent to affected individuals’ next of kin in error.

The companies were alleged to have violated HIPAA and the Consumer Fraud Act by failing to ensure the confidentiality, integrity, and availability of patient data, failing to protect against reasonably anticipated threats to the security/integrity of patient data, a failure to implement security measures to reduce risks and vulnerabilities to an acceptable level, the failure to conduct an accurate and comprehensive risk assessment, and the lack of a security awareness and training program for all members of its workforce. The case was settled with no admission of liability. There were 4 HIPAA enforcement actions by state attorneys general in 2021. New Jersey was involved in 3 of those enforcement actions.

The post December 2021 Healthcare Data Breach Report appeared first on HIPAA Journal.

November 2021 Healthcare Data Breach Report

The number of reported healthcare data breaches has increased for the third successive month, with November seeing 68 data breaches of 500 or more records reported to the HHS’ Office for Civil Rights – a 15.25% increase from October and well above the 12-month average of 56 data breaches a month. From January 1 to November 30, 614 data breaches were reported to the Office for Civil Rights. It is looking increasingly likely that this year will be the worst ever year for healthcare data breaches.

The number of data breaches increased, but there was a sizable reduction in the number of breached records. Across the 68 reported breaches, 2,370,600 healthcare records were exposed, stolen, or impermissibly disclosed – a 33.95% decrease from the previous month and well below the 12-month average of 3,430,822 breached records per month.

Largest Healthcare Data Breaches Reported in November 2021

In November, 30 data breaches of 10,000 or more records were reported to the HHS’ Office for Civil Rights, and 4 of those breaches resulted in the exposure/theft of more than 100,000 records. The average breach size in November was 34,862 records and the median breach size was 5,403 records.

The worst breach of the month saw the protected health information of 582,170 individuals exposed when hackers gained access to the network of Utah Imaging Associates. Planned Parenthood also suffered a major data breach, with hackers gaining access to its network and exfiltrating data before using ransomware to encrypt files.

Sound Generations, a non-profit that helps older adults and adults with disabilities obtain low-cost healthcare services, notified patients about two ransomware attacks that had occurred in 2021, which together resulted in the exposure and potential theft of the PHI of 103,576 individuals.

Name of Covered Entity Covered Entity Type Individuals Affected Type of Breach Location of Breached PHI Cause of Breach
Utah Imaging Associates, Inc. Healthcare Provider 582,170 Hacking/IT Incident Network Server Unspecified hacking incident
Planned Parenthood Los Angeles Healthcare Provider 409,759 Hacking/IT Incident Network Server Ransomware attack
The Urology Center of Colorado Healthcare Provider 137,820 Hacking/IT Incident Network Server Unspecified hacking incident
Sound Generations Business Associate 103,576 Hacking/IT Incident Network Server Two ransomware attacks
Mowery Clinic LLC Healthcare Provider 96,000 Hacking/IT Incident Network Server Malware infection
Howard University College of Dentistry Healthcare Provider 80,915 Hacking/IT Incident Electronic Medical Record, Network Server Ransomware attack
Sentara Healthcare Healthcare Provider 72,121 Hacking/IT Incident Network Server Unspecified hacking incident at a business associate
Ophthalmology Associates Healthcare Provider 67,000 Hacking/IT Incident Electronic Medical Record, Network Server Unspecified hacking incident
Maxim Healthcare Group Healthcare Provider 65,267 Hacking/IT Incident Email Phishing attack
True Health New Mexico Health Plan 62,983 Hacking/IT Incident Network Server Unspecified hacking incident
TriValley Primary Care Healthcare Provider 57,468 Hacking/IT Incident Network Server Ransomware attack
Broward County Public Schools Health Plan 48,684 Hacking/IT Incident Network Server Ransomware attack
Consociate, Inc. Business Associate 48,583 Hacking/IT Incident Network Server  
Doctors Health Group, Inc. Healthcare Provider 47,660 Hacking/IT Incident Network Server Patient portal breach at business associate (QRS Healthcare Solutions)
Baywood Medical Associates, PLC dba Desert Pain Institute Healthcare Provider 45,262 Hacking/IT Incident Network Server Unspecified hacking incident
Medsurant Holdings, LLC Healthcare Provider 45,000 Hacking/IT Incident Network Server Ransomware attack
One Community Health Healthcare Provider 39,865 Hacking/IT Incident Network Server Unspecified hacking incident
Educators Mutual Insurance Association Business Associate 39,317 Hacking/IT Incident Network Server Malware infection
Victory Health Partners Healthcare Provider 30,000 Hacking/IT Incident Network Server Ransomware attack
Commission on Economic Opportunity Business Associate 29,454 Hacking/IT Incident Network Server Hacked public claimant portal

Causes of November 20021 Healthcare Data Breaches

Hacking/IT incidents dominated the breach reports in November, accounting for 50 of the reported breaches. Ransomware continues to be extensively used in attacks on healthcare providers and their business associates, with the attacks often seeing sensitive patient data stolen and posted on data leak sites. The theft of patient data in these attacks also makes lawsuits more likely. Planned Parenthood, for example, was hit with a class action lawsuit a few days after mailing notification letters to affected patients.

2,327,353 healthcare records were exposed or stolen across those hacking incidents, which is 98.18% of all records breached in November. The average breach size for those incidents was 42,316 records and the median breach size was 11,603 records.

There were 11 unauthorized access/disclosure breaches in November – half the number of unauthorized access/disclosure breaches reported in October. Across those breaches, 37,646 records were impermissibly accessed or disclosed. The average breach size was 3,422 records and the median breach size was 1,553 records. There were also two reported cases of theft of portable electronic devices containing the electronic protected health information of 5,601 individuals.

November Healthcare Data Breaches by Covered Entity Type

Healthcare providers were the worst affected covered entity type with 50 reported breaches, with four of those breaches occurring at business associates but were reported by the healthcare provider. 8 data breaches were reported by health plans, 3 of which occurred at business associates, and business associates self-reported 10 data breaches. The pie chart below shows the breakdown of breaches based on where the breach occurred.

Geographic Distribution of November Healthcare Data Breaches

Healthcare data breaches of 500 or more records were reported by HIPAA-regulated entities in 32 states and the District of Columbia.

State Number of Reported Data Breaches
California & New York 7
Maryland & Pennsylvania 4
Colorado, Kentucky, Ohio, & Utah 3
Illinois, Indiana, Michigan, Minnesota, New Mexico, Tennessee, Texas, Virginia, and the District of Columbia 2
Alabama, Arizona, Arkansas, Florida, Georgia, Idaho, Kansas, Massachusetts, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Oregon, South Carolina, and Washington 1

HIPAA Enforcement Activity in November 2021

There was a flurry of HIPAA enforcement activity in November with financial penalties imposed by federal and state regulators. The HHS’ Office for Civil Rights announced a further 5 financial penalties to resolve alleged violations of the HIPAA Right of Access. In all cases, the healthcare providers had failed to provide patients with a copy of their requested PHI within a reasonable period of time after a request was received.

Covered Entity Penalty Penalty Type Alleged Violation
Rainrock Treatment Center LLC (dba Monte Nido Rainrock)

 

$160,000

 

Settlement HIPAA Right of Access
Advanced Spine & Pain Management $32,150

 

Settlement HIPAA Right of Access
Denver Retina Center $30,000

 

Settlement HIPAA Right of Access
Wake Health Medical Group

 

$10,000

 

Settlement HIPAA Right of Access
Dr. Robert Glaser

 

$100,000 Civil Monetary Penalty HIPAA Right of Access

The New Jersey Attorney General and the Division of Consumer Affairs announced in November that a settlement had been reached with two New jersey printing firms – Command Marketing Innovations, LLC and Strategic Content Imaging LLC – to resolve violations of HIPAA and the New Jersey Consumer Fraud Act. The violations were uncovered during an investigation into a data breach involving the PHI of 55,715 New Jersey residents.

The breach was due to a printing error that saw the last page of one individual’s benefit statement being attached to the benefit statement of another individual.  The Division of Consumer Affairs determined the companies failed to ensure confidentiality of PHI, did not implement sufficient PHI safeguards and failed to review security measures following changes to procedures. A financial penalty of $130,000 was imposed on the two firms, and $65,000 was suspended and will not be payable provided the companies address all the security failures identified during the investigation.

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OCR Issues Guidance on HIPAA and Disclosures of PHI for Extreme Risk Protection Orders

The Department of Health and Human Services’ Office for Civil Rights (OCR) has published new guidance to explain how the HIPAA Privacy Rule applies to disclosures of protected health information (PHI) to support applications for extreme risk protection orders.

In June 2021, the U.S. Department of Justice published model legislation to provide states with a framework for creating their own extreme risk protection order (ERPO) laws. Extreme risk protection orders temporarily prevent a person in crisis, who poses a danger to themselves or others, from accessing firearms. ERPOs are intended to improve public safety and reduce the risk of firearm injuries and deaths.

ERPO legislation permits certain entities such as law enforcement officers, family members, and healthcare providers to apply to the courts for an ERPO. Part of that process involves obtaining affidavits or sworn oral statements from petitioners and witnesses. If healthcare providers are involved in ERPOs, the HIPAA Privacy Rule applies and places restrictions on any disclosures of PHI.

The HIPAA Privacy Rule permits disclosures of PHI when those disclosures are required by law, such as in relation to statutes, regulations, court orders, and subpoenas when the disclosures comply with and are limited to the relevant requirements of such laws. OCR has confirmed that healthcare providers are permitted to disclose information about an individual to support an application for an ERPO against that individual and, in such situations, the individual will not be required to authorize the disclosure under certain conditions.

  • If required by a court order to make a disclosure of a patient’s medical records in support of an ERPO, a healthcare provider is only permitted to disclose the PHI that is specifically authorized by the court order.
  • If a state’s attorney issues a subpoena for medical records that is not accompanied by an order of a court or administrative tribunal, the requested PHI can only be provided if one of the following conditions are met:
    • The provider receives satisfactory assurances from the state’s attorney that reasonable efforts have been made to notify the subject of the PHI request about the request for access to his/her PHI
    • The provider receives satisfactory assurances state’s attorney that reasonable efforts have been made to secure a qualified protective order prohibiting use or disclosure of the PHI for purposes other than the proceeding and requiring the return to the provider or destruction of the PHI at the end of the proceeding.
    • When the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public

In all cases, HIPAA-regulated entities should make reasonable efforts to limit disclosures of PHI to the minimum necessary amount to achieve the purpose for which the PHI is being disclosed. It is also important to consult state laws, as laws may exist at the state level that provide more stringent privacy protections for individuals than those of the HIPAA Privacy Rule and not all states allow healthcare providers to apply for an ERPO.

OCR reminds HIPAA-regulated entities that federal laws such as 42 U.S.C. § 290dd-2 and 42 CFR part 2, and the Family Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99 may apply in a situation where they have information indicating a threat to public safety.

“Too often, communities bear the weight of heartbreaking tragedies caused by the epidemic of gun violence in our country,” said HHS Secretary Xavier Becerra. “Today’s guidance on HIPAA and Extreme Risk Protection Orders is an important step the Biden-Harris Administration is taking towards protecting communities from gun violence by allowing law enforcement, concerned family members, or others to prevent a person in crisis from accessing firearms.”

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New Jersey Fines Hackensack Healthcare Providers for PHI Breach and HIPAA Violations

The New Jersey Division of Consumer Affairs has agreed to settle a data breach investigation that uncovered violations of the New Jersey Consumer Fraud Act and the federal Health Insurance Portability and Accountability Act (HIPAA)

Hackensack, NJ-based Regional Cancer Care Associates is an umbrella name for three healthcare providers that operate healthcare facilities in 30 locations in Connecticut, New Jersey, and Maryland: Regional Cancer Care Associates LLC, RCCA MSO LLC, and RCCA MD LLC.

Between April and June 2019, several employee email accounts were compromised. Employees had responded to targeted phishing emails and disclosed their credentials, which allowed the scammers to access their email accounts and the protected health information (PHI) of more than 105,000 individuals. The email accounts contained PHI such as names, Social Security numbers, driver’s license numbers, health records, bank account information, and credit card details.

In July 2019, notification letters were sent to 13,047 individuals by a third-party vendor; however, the letters were mismailed to the individuals’ next-of-kin. The notification letters disclosed sensitive information such as the patient’s medical conditions, including cancer diagnoses, when consent to disclose that information had not been provided by the patients.

Across the two incidents, the PHI of more than 105,000 individuals was exposed or impermissibly disclosed, including the PHI of more than 80,000 New Jersey residents.

“New Jerseyans battling cancer should never have to worry about whether their medical providers are properly securing and protecting their personal information from cyber threats,” said New Jersey Acting Attorney General Bruck. “We require healthcare providers to implement adequate security measures to protect patient data, and we will continue to hold accountable companies that fall short.”

The companies are alleged to have violated HIPAA and the Consumer Fraud Act by failing to ensure the confidentiality, integrity, and availability of patient data, did not protect against reasonably anticipated threats to the security/integrity of patient data, did not implement security measures to reduce risks and vulnerabilities to an acceptable level, did not conduct an accurate and comprehensive risk assessment, and had not implemented a security awareness and training program for all members of its workforce.

Under the terms of the settlement, three companies will pay a financial penalty of $425,000 and are required to implement further privacy and security measures to ensure the confidentiality, integrity, and availability of PHI.

The companies are required to implement and maintain a comprehensive information security program, a written incident response plan and cybersecurity operations center, employ a CISO to oversee cybersecurity, conduct initial training for employees and annual training on information privacy and security policies, and obtain a third-party assessment on policies and procedures relating to the collection, storage, maintenance, transmission, and disposal of patient data.

“Companies have a duty to take meaningful steps to safeguard protected health and personal information, and to avoid unauthorized disclosures,” said Division of Consumer Affairs Acting Director Sean P. Neafsey. “Our investigation revealed RCCA failed to fully comply with HIPAA requirements, and I am pleased that the companies have agreed to improve their security measures to ensure consumers’ information is protected.”

New Jersey has been one of the most active states in HIPAA enforcement. In the past few months, settlements have been reached with two other companies for violations of HIPAA and the Consumer Fraud Act. In October, a New Jersey fertility clinic was fined $495,000, and two printing companies were fined $130,000 in November.

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Guidance Issued for Healthcare CISOs on Identity, Interoperability, and Patient Access

The Health Information Sharing and Analysis Center (Health-ISAC) has released guidance for Chief Information Security Officers (CISOs) on adopting an identity-centric approach to enabling secure and easy access to patient data to meet the interoperability, patient access, and data sharing requirements of the 21st Century Cures Act.

New federal regulations tied to the 21st Century Cures Act call for healthcare organizations to provide patients with easy access to their healthcare data and ensure patients can easily share their electronic health information (EHI) data wherever, whenever, and with whomever they want. The failure of a healthcare organization to implement systems to support patient access and interoperability could be considered information blocking and would be subject to fines and penalties.

The new federal requirements are for healthcare providers and insurers to allow data sharing through Application Programming Interfaces (APIs) that operate on the Fast Healthcare Interoperability and Resources (FHIR) standard. Healthcare providers and insurers are required to establish APIs to allow patients to access their EHI; however, providing patients with easy access to their healthcare data has the potential to introduce security vulnerabilities.

Health-ISAC says that in order to provide easy access to patient data, multiple privacy, security, and usability challenges need to be addressed, all of which are rooted in identity. When users request access to their data, strong authentication controls must be in place to verify that the person requesting EHI is who they say they are. For many years, patient matching problems have plagued the healthcare industry, and without a national patient identifier, those problems exist to this day. Those issues must also be addressed to ensure the correct EHI is provided.  Also, if an individual wants to only share part of their EHI, it needs to be possible for a portion of the data to be easily shared.

H-ISAC Framework for Managing Identity

Health-ISAC suggests a Framework for Managing Identity (above) that covers all of those functions; however, privacy and security issues also need to be addressed. For example, if a patient wants to authorize the use of EHI on behalf of someone else that he/she cares for, such as an elderly relative or a minor child, that must be possible. It must also be possible for a patient to delegate access privileges if they are being cared for by someone else, and for appropriate authentication controls to be in place to accommodate such requests. API-level security is also required. FHIR APIs are in the public domain, so they must be secured after authorization to use is granted.

Health-ISAC suggests that healthcare organizations should adopt an identity-centric approach to data sharing to solve these issues. “The most effective way of mitigating the risk that these issues pose to organizations is through the implementation of a modern, robust, and secure identity infrastructure that can securely authenticate and authorize users and incoming requests, enforce the appropriate consent requests, and tightly govern the use of identities,” said Health-ISAC. “By design, this is exactly what the Health-ISAC framework is meant to achieve.”

Additionally, Health-ISAC strongly recommends implementing multi-factor authentication, as while this is not explicitly required by the new ONC and CMS Rules, guidance issued by the government strongly points to the use of MFA. There are risks associated with not implementing MFA due to its importance for authentication.  The HHS’ Office for Civil Rights (OCR) has fined health organizations for HIPAA violations related to inadequate authentication in the past. Health-ISAC has produced a white paper – All About Authentication – which explains the best approach for implementing MFA.

“Identity is a journey. As the healthcare industry focuses on digital adoption, identity will continue to play a foundational role. Whether your implementation of a modern identity system is driven by regulatory and compliance requirements, security and privacy concerns, or a desire to improve customer experience, a well-architected, robust digital identity solution can address all of these drivers,” concludes Health-ISAC.

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HHS Launches 405(d) Program Website Providing Resources to Help Mitigate Healthcare Cybersecurity Threats

The Department of Health and Human Services has launched a new website that offers advice and resources to help the healthcare and public health sector mitigate cybersecurity threats.

The website was created as part of the HHS 405(d) Aligning Health Care Industry Security Approaches Program, which was established in response to the Cybersecurity Act of 2015. The Cybersecurity Act of 2015 called for the HHS to establish the program and a Task Group to enhance cybersecurity and align industry approaches by developing a common set of voluntary, consensus-based, and industry-led cybersecurity guidelines, practices, methodologies, procedures and processes that healthcare organizations can use.

More than 150 individuals from industry and the federal government have collaborated under the program and provided insights into how best to mitigate cyberthreats. The new website supports the motto, Cyber Safety is Patient Safety, and provides videos and other educational material to raise awareness of pertinent threats along with vetted cybersecurity resources to drive behavioral change and move toward consistency in mitigating key threats to healthcare organizations. Through the website, organizations in the HPH sector can subscribe to a bi-monthly 405(d) newsletter and will have easy access to threat-specific products to support cybersecurity awareness and training efforts.

“The new 405(d) Program website is a step forward for HHS to help build cybersecurity resiliency across the Healthcare and Public Health Sector. This is also an exciting moment for the HHS Office of the Chief Information Officer in our ongoing partnership with industry,” said Christopher Bollerer, HHS Acting Chief Information Security Officer.

“This website is the first of its kind! It’s a unique space where the healthcare industry can access vetted cybersecurity practices specific to the HPH sector on a federal government website,” said Erik Decker, 405(d) Task Group Industry co-lead. “I think it’s a great resource for the HPH sector to turn to and will surely be a go-to site for organizations that want to better protect their patients and facilities from the latest cybersecurity threats.”

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26th Annual Compliance Institute: March 28 – 31, 2022

The Health Care Compliance Association (HCCA) will be hosting the 26th Annual Compliance Institute at the Phoenix Convention Center, AZ, March 28 – 31, 2022.

The HCCA is a member-based association for healthcare compliance professionals that is dedicated to enabling the lasting success and integrity of all professionals working for, with, or supporting healthcare organizations. Established in 1996, the HCCA now has more than 12,000 members across the United States.  The HCCA promotes the highest standards in compliance programs, creates high-quality educational training events, and provides a forum for interaction and information exchange within the healthcare compliance community.

The Compliance Institute is the HCCA’s primary educational and networking event. Running over 4 days, attendees will be able to attend 109 educational sessions, benefit from professional development opportunities, and will be able to network and improve their career prospects.

The educational sessions highlight real-world compliance issues, emerging trends, and practical applications that attendees can use to strengthen their compliance programs., with the 2022 event covering the following subject areas:

  • Auditing and monitoring
  • Behavioral health
  • Compliance law
  • General compliance/hot topics
  • How to succeed as a compliance officer
  • Investigations
  • Physician compliance
  • Post-acute care
  • Privacy and security
  • Risk management
  • Telehealth

The event will be of great benefit to healthcare compliance professionals, risk managers, privacy officers, coding and billing specialists, healthcare regulators, government personnel, nurse managers and executives, staff educators and trainers, health information management specialists, CIOs, healthcare senior executives, healthcare professionals, healthcare journalists and researchers.

26th Annual Compliance Institute

The conference will run from Monday, March 28 to Thursday, March 31 at the Phoenix Convention Center, AZ.

If it is not possible to attend in person, this year there will be the option of attending virtually from Tuesday, March 29 to Thursday, March 31. Virtual visitors will be able to attend 47 educational sessions which are being live-streamed from the conference center.

Register for the Conference

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HHS’ Office for Civil Rights Imposes Further 5 Financial Penalties for HIPAA Right of Access Violations

The HHS’ Office for Civil Rights (OCR) is continuing with its enforcement of compliance with the HIPAA Right of Access and has recently announced a further 5 financial penalties. The HIPAA Right of Access enforcement initiative was launched in the fall of 2019 in response to a significant number of complaints from patients who had not been provided with timely access to their medical records.

The HIPAA Privacy Rule requires covered entities to provide individuals with access to their medical records. A copy of the requested information must be provided within 30 days of the request being received, although an extension of 30 days may be granted in limited circumstances. HIPAA-covered entities are permitted to charge patients for exercising this important Privacy Rule right, but may only charge a reasonable, cost-based fee. Labor costs are only permitted for copying or otherwise creating and delivering the PHI after it has been identified.

The enforcement actions to date have not been imposed for charging excessive amounts, only for impermissibly refusing to provide a copy of the requested records or for unnecessary delays. In some cases, patients have had to wait many months before they were provided with a copy of their records.

The latest announcement by OCR brings the total number of HIPAA Right of Access enforcement actions under the 2019 enforcement initiative up to 25.

In all of the new cases below, OCR determined the healthcare providers were in violation of 45 C.F.R. § 164.524 and had not provided timely access to protected health information about the individual after receiving a request.

Advanced Spine & Pain Management, a provider of chronic pain-related medical services in Cincinnati and Springboro, OH, agreed to settle OCR’s investigation and paid a $32,150 financial penalty and will be monitored by OCR for compliance with its corrective action plan for 2 years. The investigation stemmed from a complaint from a patient who requested his medical records on November 25, 2019, but was not provided with the records until March 19, 2020.

Denver Retina Center, a Denver, CO-based provider of ophthalmological services, settled its investigation with OCR and paid a $30,000 financial penalty and will be monitored for compliance with its corrective action plan for 12 months. A patient alleged she had requested her records in December 2018 but did not receive a copy of her records until July 26, 2019. OCR had provided technical assistance to the healthcare provider following receipt of a previous HIPAA Right of Access complaint from the same patient and closed the case. When evidence was received of continued non-compliance the case was reopened. OCR determined that in addition to the delay, Denver Retina Center’s access policies and procedures were not compliant with the HIPAA Privacy Rule, as required by 45 C.F.R. § 164.530(i).

Rainrock Treatment Center LLC (dba Monte Nido Rainrock), a Eugene, OR-based provider of residential eating disorder treatment services, settled OCR’s investigation and paid a $160,000 financial penalty and will be monitored for compliance with the corrective action plan for 12 months. OCR had received three complaints from a patient who had not been provided with a copy of her medical records. The patient had requested a copy of her records on October 1, 2019, and November 21, 2019, and did not receive the requested records until May 22, 2020.

Wake Health Medical Group, a Raleigh, NC-based provider of primary care and other health care services, settled OCR’s investigation and paid a $10,000 financial penalty and has agreed to take corrective action to prevent further HIPAA Right of Access violations. OCR had received a complaint from a patient who requested a copy of her medical records on June 27, 2019 and paid a $25 flat fee, which is the standard fee charged by Wake Health Medical Group for providing copies of medical records. As of the date of the settlement, the patient has still not been provided with the requested records.

Dr. Robert Glaser, a New Hyde Park, NY-based cardiovascular disease and internal medicine doctor, did not cooperate with OCR during the investigation, although did not contest the findings and waived his right to a hearing. A civil monetary penalty of $100,000 was imposed by OCR. An investigation was launched following receipt of a complaint from a former patient who alleged he had made several written and verbal requests for a copy of his medical records between 2013 and 2014. The complaint was filed with OCR on November 9, 2017, and the case was closed by OCR on December 15, 2017, after advising Dr. Glaser to investigate the complaint and provide the requested records if the requests were in line with the HIPAA Right of Access. The patient filed a further complaint with OCR on March 20, 2018, and provided evidence of further written requests. OCR tried to contact Dr. Glaser on multiple occasions by letter and phone, but he repeatedly failed to respond, hence the decision to impose a civil monetary penalty.

“Timely access to your health records is a powerful tool in staying healthy, patient privacy and it is your right under law,” said OCR Director Lisa J. Pino. “OCR will continue its enforcement actions by holding covered entities responsible for their HIPAA compliance and pursue civil money penalties for violations that are not addressed.”

The post HHS’ Office for Civil Rights Imposes Further 5 Financial Penalties for HIPAA Right of Access Violations appeared first on HIPAA Journal.

October 2021 Healthcare Data Breach Report

October saw 59 healthcare data breaches of 500 or more records reported to the Department of Health and Human Services’ Office for Civil Rights, which represents a 25.5% increase from September. Over the past 12 months, from November 2020 to October 2021, there have been 655 reported breaches of 500 or more records, 546 of which have been reported in 2021.

Healthcare Data Breaches (November 20-October 21)

The protected health information (PHI) of 3,589,132 individuals was exposed, stolen, or impermissibly disclosed across the 59 reported data breaches, which is 186% more records than September. Over the past 12 months, from November 2020 to October 2021, the PHI of 39,938,418 individuals has been exposed or stolen, with 34,557,664 individuals known to have been affected by healthcare data breaches so far in 2021.

Healthcare records breached (november 20-october 21)

Largest Healthcare Data Breaches in October 2021

There were 18 data breaches reported to the HHS’ Office for Civil Rights in October that impacted 10,000 or more individuals, as detailed in the table below.

Name of Covered Entity State Covered Entity Type Individuals Affected Type of Breach Breach Cause
Eskenazi Health IN Healthcare Provider 1,515,918 Hacking/IT Incident Ransomware attack
Sea Mar Community Health Centers WA Healthcare Provider 688,000 Hacking/IT Incident Ransomware attack
ReproSource Fertility Diagnostics, Inc. MA Healthcare Provider 350,000 Hacking/IT Incident Ransomware attack
QRS, Inc. TN Business Associate 319,778 Hacking/IT Incident Unauthorized network server access
UMass Memorial Health Care, Inc. MA Business Associate 209,048 Hacking/IT Incident Phishing attack
OSF HealthCare System IL Healthcare Provider 53,907 Hacking/IT Incident Ransomware attack
Educators Mutual Insurance Association UT Health Plan 51,446 Hacking/IT Incident Unauthorized network access and malware infection
Lavaca Medical Center TX Healthcare Provider 48,705 Hacking/IT Incident Unauthorized network access
Professional Dental Alliance, LLC PA Healthcare Provider 47,173 Unauthorized Access/Disclosure Phishing attack on a vendor
Nationwide Laboratory Services FL Healthcare Provider 33,437 Hacking/IT Incident Ransomware attack
Professional Dental Alliance of Michigan, PLLC PA Healthcare Provider 26,054 Unauthorized Access/Disclosure Phishing attack on a vendor
Syracuse ASC, LLC NY Healthcare Provider 24,891 Hacking/IT Incident Unauthorized network access
Professional Dental Alliance of Georgia, PLLC PA Healthcare Provider 23,974 Unauthorized Access/Disclosure Phishing attack on a vendor
Professional Dental Alliance of Florida, LLC PA Healthcare Provider 18,626 Unauthorized Access/Disclosure Phishing attack on a vendor
Professional Dental Alliance of Illinois, PLLC PA Healthcare Provider 16,673 Unauthorized Access/Disclosure Phishing attack on a vendor
Professional Healthcare Management, Inc. TN Healthcare Provider 12,306 Hacking/IT Incident Ransomware attack
Professional Dental Alliance of Tennessee, LLC PA Healthcare Provider 11,217 Unauthorized Access/Disclosure Phishing attack on a vendor
Professional Dental Alliance of New York, PLLC PA Healthcare Provider 10,778 Unauthorized Access/Disclosure Phishing attack on a vendor

Ransomware attacks continue to plague healthcare organizations and threaten patient safety. Half of the top 10 data breaches involved ransomware, including the top three data breaches reported in October.

The worst breach of the month was reported by Eskenazi Health. The PHI of more than 1.5 million patients was exposed and patient data is known to have been stolen in the attack. A major ransomware attack was also reported by Sea Mar Community Health Centers. Its systems were first compromised in December 2020, the ransomware attack was identified in March 2021, and Sea Mar was notified about the posting of patient data on a darknet marketplace in June. It took until late October to issue notifications to affected individuals.

Hackers often gain access to healthcare networks through phishing attacks, and phishing remains the leading attack vector in ransomware attacks. Large quantities of sensitive data are often stored in email accounts and can easily be stolen if employees respond to phishing emails. A phishing attack on UMass Memorial Health Care resulted in the exposure of the PHI of 209,048 individuals, and a phishing attack on a vendor used by the Professional Dental Alliance exposed the PHI of more than 174,000 individuals.

Causes of October 2021 Healthcare Data Breaches

Data breaches classified as hacking/IT incidents, which include ransomware attacks, were the main cause of data breaches in October. 57.63% of all breaches reported in the month were classified as hacking/IT incidents and they accounted for 94.14% of all breached records (3,378,842 records). The average size of the data breaches was 99,378 records and the median breach size was 5,212 records.

Causes of October 2021 healthcare data breaches

22 breaches were classified as unauthorized access/disclosure incidents and involved the PHI of 200,887 individuals. Those breaches include the phishing attack that affected the Professional Dental Alliance. The average breach size was 9,131 records and the median breach size was 4,484 records.

There were 4 breaches reported that involved the loss or theft of physical PHI or electronic devices containing PHI, 3 of which were theft incidents and 1 was a lost laptop computer. The PHI of 9,403 individuals was exposed as a result of those incidents. The average breach size was 2,351 records and the mean breach size was 1,535 records.

Location of breached protected health information -October 2021

Healthcare Data Breaches by HIPAA-Regulated Entity Type

Healthcare providers were the worst affected covered entity type with 43 reported breaches. 8 data breaches were reported by business associates of HIPAA-covered entities and 8 were reported by health plans. Many data breaches occur at business associates of HIPAA-covered entities but are reported by the affected covered entity. The pie chart below shows the breakdown of breaches based on where they occurred.

October 2021 healthcare data breaches by HIPAA-regulated entity type

Healthcare Data Breaches by State

Healthcare data breaches were reported by HIPAA-regulated entities in 26 states. Pennsylvania was the worst affected state with 12 reported breaches, although 11 of those breaches were the same incident – the phishing attack on the Professional Dental Alliance vendor that was reported separately by each affected HIPAA-covered entity.

State No. Breaches
Pennsylvania 12
California 5
Illinois, Indiana, & Texas 4
New York & Washington 3
Connecticut, Florida, Massachusetts, New Jersey, North Carolina & Tennessee 2
Alabama, Arkansas, Kansas, Kentucky, Minnesota, Mississippi, Nebraska, Ohio, South Carolina, Utah, Virginia, & West Virginia 1

HIPAA Enforcement Activity in October 2021

There was only one HIPAA enforcement action announced in October. The New Jersey Attorney General agreed to settle an investigation into a data breach reported by Diamond Institute for Infertility and Menopause that resulted in the exposure of the PHI of 14,663 New Jersey residents.

The New Jersey Department of Law and Public Safety Division of Consumer Affairs uncovered violations of 29 provisions of the HIPAA Privacy and Security Rules, and violations of the New Jersey Consumer Fraud Act. In addition to paying $495,000 in civil monetary penalties and investigation costs, Diamond agreed to implement additional measures to improve data security.

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