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By Eric Topor
The Department of Health and Human Services May 21 announced a resolution agreement with Idaho State University (ISU) outpatient clinics--over a breach of approximately 17,500 patient records--under which the health care provider will pay $400,000 and implement a corrective action plan (CAP).
ISU notified the HHS Office for Civil Rights (OCR) of the data breach in August 2011.
OCR's November 2011 investigation report revealed Health Insurance Portability and Accountability Act Security Rule violations between 2007 and 2012 involving ISU's failure to conduct a risk analysis of the confidentiality of its electronic patient records; inadequate implementation of security measures to reduce patient record breaches; and inadequate review of information system activity to determine whether patient records were inappropriately disclosed.
The investigation determined that ISU patient records were unsecured for at least 10 months after firewall protections on ISU servers were disabled.
“Risk analysis, ongoing risk management, and routine information system reviews are the cornerstones of an effective HIPAA security compliance program,” OCR Director Leon Rodriguez said in a statement.
“We want to reiterate that as far as we are concerned, and as far as our due diligence demonstrates, as well as the third party that we hired to come in and do an audit, that no patient records were accessed, and data was not compromised,” Greg Ehardt, HIPAA/assistant university compliance officer at Idaho State University, told BNA May 22.
“As we recognized that the firewall had been disabled for maintenance purposes, unfortunately that was not restored properly.” As ISU did its “due diligence and our external audit, we determined that as far as we were concerned, no patient records had been accessed. But we felt it appropriate, given the incident, that we need to report this to the Office for Civil Rights for their determination as well.”
He added that his hiring by the university was one of several steps ISU has taken to “fortify the security measures here.” Ehardt added that the university has implemented “an event logging system that will more closely track these types of events.”
The university also brought in and centralized the IT of the clinics, whereas before it was somewhat decentralized,” he said.
“We feel that with the number of changes that we've made, and the remediation that we've taken upon ourselves, that we're a much stronger, more fortified program and system at this time.”
The CAP, which began May 13 and will extend for two years, designates ISU as a “hybrid entity” and requires ISU to identify all covered health care components in its clinic system. The plan requires ISU to submit its current risk management plan, a report of its information system activity across all clinics, and a compliance gap analysis report, and to implement any changes to the plans and procedures suggested by HHS after review.
ISU is required to notify HHS if any ISU employee fails to comply with privacy and security procedures under the CAP, following an internal review by ISU. The CAP requires any notification to include the name of the employee involved, which security policies or procedures were implicated, the steps ISU has taken to mitigate any privacy or security breach, and what steps will be taken to prevent future similar occurrences.
The CAP also requires ISU to submit annual reports detailing security and privacy measures implemented, system activity review measures, an update of compliance gap analysis activity, any reportable events, and a signed attestation by an ISU officer that he or she has reviewed the report and believes it to be accurate.
ISU is required to retain all documents and records relating to the CAP for at least six years.
In January, another entity in Idaho, a small nonprofit hospice, agreed to pay $50,000 to HHS to settle allegations of federal data security rule violations over the loss of a laptop containing the personal health information of 441 patients. That settlement was the first involving a breach of protected health information affecting fewer than 500 individuals under the HIPAA Security Rule, HHS said (12 PVLR 41, 1/7/13).
Full text of the resolution agreement is available at http://op.bna.com/hl.nsf/r?Open=etor-97xjd4.
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