Comprehensive Neurology, PC

The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a settlement with Comprehensive Neurology, (Comprehensive), a small New York neurology practice, concerning a potential violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule. The settlement resolves an OCR investigation of a ransomware attack against Comprehensive. OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules, which set forth the requirements that covered entities (health plans, health care clearinghouses, and most health care providers), and business associates must follow to protect the privacy and security of protected health information (PHI). The HIPAA Security Rule establishes national standards to protect and secure our health care information systems by requiring administrative, physical, and technical safeguards to ensure the confidentiality, integrity, security, and availability of electronic PHI (ePHI). Ransomware and hacking are the primary cyberthreats to electronic health information in health care. Ransomware is a type of malware (malicious software) designed to deny access to a user’s data, usually by encrypting it until a ransom is paid. The HIPAA Security Rule Risk Analysis provision is a key Security Rule requirement and the foundation for effective cybersecurity practices and the protection of ePHI. The settlement resolves OCR’s investigation of a ransomware attack against Comprehensive. In December 2020, OCR received a breach report from Comprehensive that stated that its IT network, including all of its ePHI, had been encrypted and rendered inaccessible by ransomware. Comprehensive determined that 6,800 individuals may have been affected. The compromised ePHI included demographic and clinical information. OCR’s investigation found that Comprehensive failed to conduct an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the confidentiality, integrity, and availability of the ePHI held by Comprehensive. Comprehensive agreed to implement a corrective action plan that will be monitored by OCR for two years and paid $25,000 to OCR. Under the corrective action plan, Comprehensive will be required to take specific steps toward resolving potential violations of the HIPAA Security Rule, including: • Conducting an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the ePHI in its information systems; • Developing and implementing a risk management plan to address and mitigate reduce security risks and vulnerabilities identified in the risk analysis; • Reviewing, and to the extent necessary, revising its written policies and procedures to comply with the HIPAA Rules; and • Training its workforce on its HIPAA policies and procedures. The resolution agreement and corrective action plan may be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/index.html The HHS Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information may be found at: https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf