It does not take a huge breach of privacy to result in a huge fine — in this case, malware that potentially compromised 1670 patient files of PHI cost UMASS $650,000 in fines. This emphasizes the concept that there is no such thing as a “small breach” of PHI.
The OCR announcement of the fine appears below:
The University of Massachusetts Amherst (UMass) has agreed to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. The settlement includes a corrective action plan and a monetary payment of $650,000, which is reflective of the fact that the University operated at a financial loss in 2015.
On June 18, 2013, UMass reported to the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) that a workstation in its Center for Language, Speech, and Hearing (the “Center”) was infected with a malware program, which resulted in the impermissible disclosure of electronic protected health information (ePHI) of 1,670 individuals, including names, addresses, social security numbers, dates of birth, health insurance information, diagnoses and procedure codes. The University determined that the malware was a generic remote access Trojan that infiltrated their system, providing impermissible access to ePHI, because UMass did not have a firewall in place.
OCR’s investigation indicated the following potential violations of the HIPAA Rules:
- UMass had failed to designate all of its health care components when hybridizing, incorrectly determining that while its University Health Services was a covered health care component, other components, including the Center where the breach of ePHI occurred, were not covered components. Because UMass failed to designate the Center a health care component, UMass did not implement policies and procedures at the Center to ensure compliance with the HIPAA Privacy and Security Rules. (Note: The HIPAA Privacy Rule permits legal entities that have some functions that are covered by HIPAA and some that are not to elect to become a “hybrid entity.” To successfully “hybridize,” the entity must designate in writing the health care components that perform functions covered by HIPAA and assure HIPAA compliance for its covered health care components.)
- UMass failed to implement technical security measures at the Center to guard against unauthorized access to ePHI transmitted over an electronic communications network by ensuring that firewalls were in place at the Center.
- Finally, UMass did not conduct an accurate and thorough risk analysis until September 2015.
“HIPAA’s security requirements are an important tool for protecting both patient data and business operations against threats such as malware,” said OCR Director Jocelyn Samuels. “Entities that elect hybrid status must properly designate their health care components and ensure that those components are in compliance with HIPAA’s privacy and security requirements.”
In addition to the monetary settlement, UMass has agreed to a corrective action plan that requires the organization to conduct an enterprise-wide risk analysis; develop and implement a risk management plan; revise its policies and procedures, and train its staff on these policies and procedures. The Resolution Agreement and Corrective Action Plan may be found on the OCR website at http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/umass.