OCR Archives

Do you have all of your HIPAA training documented?

Suze Shaffer January 7, 2019June 29, 2022

What do you know about HIPAA enforcement?
Just imagine you were investigated by CMS or the OCR, what would they find?
How confident are you in your medical and/or HIPAA documentation?
Do you have the appropriate documentation to protect your organization?

The Office for Civil Rights (OCR) is very serious about ensuring your organization is educating employees on patient rights and securing PHI. During a recent investigation in Florida an organization was fined $100K for each year they could not produce documented HIPAA training. The first year they only had 3 employees! They were fined for five years, $500K. Once you are under investigation, they review ALL of your documentation, not just what they originally requested. You do not want to end up being in the willful and wanton neglect category. This is where the big fines are calculated.

If you have a patient complaint or suffer a data breach, the best advice is to document, document, AND document! OH, did I mention… DOCUMENT? Next, cooperation. If they ask for something, give it to them. Nothing more, nothing less, but give them what they ask for. Show the OCR you are trying to do the right thing. After all, how would you like it if the information that was compromised was yours? Wouldn’t you want the organization to do what they could to stop the breach or prevent another one from happening?

Remember the MD Anderson in Texas fines? They had multiple devices lost containing unencrypted ePHI. They claimed that they were not obligated to encrypt its devices, and stated that the ePHI that was involved was for “research,” and thus was not subject to the HIPAA non-disclosure requirements. They challenged the OCR and the Judge ruled in favor of the OCR and MD anderson was ordered to pay $4,348,000 in civil money penalties. The quote from OCR Director Roger Severino: “OCR is serious about protecting health information privacy and will pursue litigation, if necessary, to hold entities responsible for HIPAA violations”.

At the NIST/OCR conference in Washington DC, the director along with other members of the OCR staff reminded organizations about enforcement. This is NOT going away. Patient information is extremely valuable to criminals. The days of just a slap on the wrist because you didn’t conduct risk assessment, conduct HIPAA training, or you can’t prove your HIPAA compliance is over. Every organization that has anything to do with patient information must get on board and understand HIPAA. There is NO certificate to prove you are HIPAA compliant, the proof is in your documentation. So I ask one more time… How well do you trust your HIPAA documentation?

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Data breaches of 2018

Suze Shaffer December 21, 2018June 29, 2022

We hear on the news about data breaches almost daily. Some are credit card theft, our personal information being sold, and then are medical data breaches. These are extremely worrisome as this is where identity theft can start. The medical community is a major target for that very reason, medical records are the main source of complete information to steal personal information.

Do you know how many individual patient records have been compromised in 2018?

11,785,675 patient records were reported as breaches to the Office of Civil Right (OCR) in 2018 that were over 500 records per incident. Keep in mind this does NOT include breaches under 500 records.

https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf;jsessionid=3F3012CA56DF3E4D79031A59CCBBBA4D

Plus 944,595 patient records that had been exposed that have already been archived according to the OCR portal.

At the NIST/OCR October conference, they talked about how medical offices use the excuse… “I didn’t know”. They also said that was not an acceptable answer any longer. They can and will fine organizations that are not HIPAA compliant. You are 4 times more likely to get hacked than to have your equipment stolen and this does not even include the breaches caused by unauthorized access. Needless to say data breaches are on the rise no matter what angle you are looking at.

So as we close out 2018 and venture into 2019…
You MUST be diligent and keep up to date on the latest technology for data security.
You MUST make sure your employees are WELL educated on data security.
You MUST document your compliance efforts.

In the words from the Office for Civil Rights, “If it’s not documented, it doesn’t exist”!

Be safe out there in the World Wide Web… it’s a wonderful but dangerous place!

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Spoofing, Phishing, and how to avoid getting caught in the middle

Suze Shaffer November 15, 2018June 29, 2022

After attending the Office for Civil Rights (OCR) annual webcast, many things were confirmed that we thought may have been rumors. First of all, medical offices are targets of hacking because you hold everything needed for identity theft.

What is identity theft? Most people think of it as their credit card being stolen, or even their tax returns. True, that is identity theft but there is also another component that is not often talked about. That is, assuming someone else’s identity for health care purposes. Imagine someone assumes your identity and has a surgery and “corrects” your medical record and changes your blood type. Then, you are involved in a car accident and receive a blood transfusion but it’s the WRONG blood. Yes, this can happen. We are not sure how often, but with the rise of medical records being stolen we could see this happen more often. Knowing where your data is located and how it is stored is a starting point in protecting this valuable information. Conducting a risk analysis and having an ongoing risk management is mandatory under HIPAA. During this process you will uncover potential vulnerabilities. Once you mitigate these risks, you may be able to avoid a data breach.

Protecting yourself and your organization is one in the same. Practice these safety tips at work and at home:

Make sure your operating system updates are current as well as your anti-virus and anti-malware.
Scan for viruses and malware after every update.
If you use personal devices to access ePHI or work files, be sure to use enterprise versions of anti-virus and anti-malware. Free versions typically are not robust enough.
NEVER use free Wi-Fi even if you are not accessing any patient information. You could pick up malware from someone that has spoofed the Wi-Fi network that you thought you were logging into.
NEVER click on links within emails that claim to be urgent or a free offer of some type. Typical phishing expeditions start in this manner. After you click, they ask for certain information they are lacking about you or they may ask for everything! Sometimes, this is merely a tactic to get you to go to a certain website and place malware on your computer and you never even know it.
NEVER click on a link within an email asking you to verify your identity. You wouldn’t show a stranger on the street your driver’s license just because they asked to see it, then why would you “verify” your identity with someone invisible in your email? Again, this is how spear phishing starts.
NEVER click on an attachment within an email unless you are expecting it, even if you know the person that sent it. Their email could have been hacked and you are being spoofed into thinking it is from them. This includes messages from FedEx, UPS, and the IRS. Best practices is to open your web browser and go to their website and sign in.
NEVER click on links in text messages unless you are expecting one, such as you just signed up for text messages from a service provider. Bank customers are being spoofed into clicking on links in text messages and taking you to what looks like your bank. Guess what… it’s NOT your bank but looks like it!

I have said this before… the World Wide Web (WWW) is the new Wild Wild West. The only difference is, in the old wild wild west you could see danger coming on the horizon and prepare. The World Wide Web, the dangers are there, but they are invisible.

Be safe out there!

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Cost of cyber attacks on healthcare are steadily rising

Suze Shaffer August 1, 2018June 29, 2022

Why are so many medical offices being attacked? Simple, this is a one stop shop for everything needed for identity theft and many medical practices do not have appropriate safeguards in place. Business associates have even been the target or the entry point. HIPAA requires certain security safeguards to be in place to ensure the safety and security of Protected Health Information (PHI).

There have been 188 data breaches of 500 or more patient records in the first 6 months of this year, and in April alone there were 42. Thirteen of the 188 have already been resolved. https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf
These breaches include small medical practices, business associates, and hospitals. Small and large. Paper and electronic. No one is immune. Many organizations think they are too small to get hit, but the fact is the most common problem is untrained staff that unknowingly cause this to happen. Education is the key to avoiding this catastrophe from destroying your reputation. Of course you still need to certain technical safeguards in place, but even then it only takes one click of a mouse to bring your network down.

Here are some areas to consider:

How would you process a data breach?
How would you handle the reputation management of the breach?
How would you pay for the cost of breach and the investigations?

Having a breach notification plan in place before a breach occurs is critical to reducing the damage. You must have processing in place to shut the system down, continue manually, and report to the appropriate authorities.

Consider the lack of trust from your patients since their information was compromised from your office. No matter if it was your fault or that of a business associate this could have a negative impact on your patient database.

Breaches are costly on many fronts, the first being the cost of the notification of the patients, investigations, downtime, and the mitigation of the source of the breach. In 2013 the Ponemon Institute reported that a data breach cost $233 per medical record, now in the 2018 the report states a healthcare breach can cost on average $408 per medical record.
https://www.ibm.com/security/data-breach

Keep in mind if you do not know which records were breached then everyone must be included in the notification process. What could turn out to be the most costly is the fines and penalties associated with the breach. Depending on how and when you processed the breach is one determining factor. Also once the investigation is complete, if it is discovered this was an ongoing problem and was not mitigated, then you could be found in willful and wanton neglect. This is NOT a place you want to find yourself! The Office for Civil Rights (OCR) can also fine you for not conducting a thorough enough risk analysis thus leaving vulnerabilities untouched. How well do you trust your efforts in securing your data? Have you conducted a risk assessment to determine if what you have in place is sufficient?

How can Aris help?

First of all we conduct a thorough risk analysis that uncovers vulnerabilities and create a risk management plan so that you can mitigate those risks.
Since written documentation is also part of HIPAA compliance, we provide the necessary privacy and security policies, procedures, and documentation needed for state and federal regulatory requirements.
We also offer HIPAA training that includes privacy and security and any custom requests.
If you are one of the many organizations that simply do not have the time to implement your HIPAA program, we can do that for you as well. Month to month, no long term contracts!

If you would like a free HIPAA checkup call 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

Workstation Security

Suze Shaffer June 19, 2018June 29, 2022

HIPAA Compliance is more than just about a patient’s right to access their information. Although the HIPAA Privacy Rule is how most of this began, it is so much more now! The HIPAA Security Rule outlines administrative safeguards, physical, and technical security. Most organizations are so busy trying to figure out how to protect themselves from the unknown (technical concerns) that they forget about the actual physical security. We are not just talking about building security systems, but how you secure the individual devices that are utilized within your facility and those who travel with portable devices.

Here are some helpful ideas to review with your particular situation:

Although utilizing a security system that has motion sensors is better than nothing, using security cameras usually discourages theft.
Conduct a walk through of your facility and create an inventory list of all devices that access or store ePHI. Knowing what you have, where it is located, and if it contains ePHI is essential in securing your data. This includes portable devices and small electronic media. Remember, printers, copiers, and scanners can store data as well.
Review the location of all devices that access or store ePHI. Ensure they are not located in an area that could be easily accessed by an unauthorized person or utilize cable locks. If screens are viewable and cannot be relocated, the use of privacy screens are highly recommended. Encryption is recommended on any device that contains ePHI. If the devices are transported they should be encrypted even if they do not contain ePHI. If they are ever lost or stolen and the encryption is engaged, it would not be a reportable breach.
If your USB drives are not used, locks should be installed. This is an inexpensive method to protect the network. If your workstations utilize CD/DVD drives, these should be disabled as well. Another option would be to configure this through a Microsoft Group Policy.
Make sure paper PHI is not left in areas that could be accessed by another as well. This includes where you store your excess paper charts. These areas should be locked when not in use. It is also recommended to utilize signage instructing “Employees Only”.
Employees can be your biggest asset or your largest liability. Training your employees on computer security is an ongoing process. Annual HIPAA training should include the HIPAA privacy rule and HIPAA security rule. Also, add monthly security reminders to keep HIPAA fresh in their minds. Continuing education is the key to safety.
HIPAA Policies and procedures are the backbone of an organization. Properly trained employees know and understand what is required and needed. The data that a health care provider has in its possession is priceless. This data must be secure physically and technically. All of this is necessary to avoid a data breach.

If an organization fails to secure patient information the Office for Civil Rights (OCR) will open an investigation and the organization can end up with massive fines. These fines have ranged from $250K to $3.5M. Although the fines are based on the organization’s ability to pay, the days of receiving just a $50K fine seems to be over. Best practices would be to review your HIPAA risk analysis and make sure it is thorough. Some online risk assessments unfortunately do not uncover all of your vulnerabilities. The OCR could consider this as willful neglect even though you didn’t know. Make sure you update your risk management plan and mitigate those vulnerabilities. Small oversights could cost you a fortune.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

“Simplifying HIPAA through Partnership, Education, and Support”

Do HIPAA Fines go away when a practice or business closes?

Suze Shaffer March 26, 2018February 2, 2024

By Aris Medical Solutions

Many medical practices and business associates have the misconception that if they are fined they can simply close their doors and not be obligated to pay the fines or penalties. We have been asked if this will work many times. The Office for Civil Rights (OCR) has answered this haunting question.

Three years ago the OCR received an anonymous complaint against Filefax, Inc. that transported 2,150 patient files to be shredded. These files were left in an unlocked truck in their parking lot, or by granting permission to an unauthorized person to remove the files from Filefax, and leaving the Protected Health Information (PHI) unsecured outside the Filefax facility.

Although Filefax shut their doors during the course of the OCR’s investigation they were still obligated under the law. In 2016, a court in unrelated litigation appointed a receiver to liquidate its assets. In addition to a $100,000 monetary settlement, the receiver has agreed, on behalf of Filefax, to properly store and dispose of remaining medical records found at Filefax’s facility in compliance with HIPAA.

The first step in protecting your practice or business is to conduct a thorough security risk assessment and identify vulnerabilities and workflow. From there you can develop a risk management plan to ensure you document your compliance efforts and mitigate risks.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Partnership, Education, and Support”

Updating your Contingency Plan

Suze Shaffer March 25, 2018February 1, 2024

By Aris Medical Solutions

Contingency Planning is more than just a power outage or how to backup and restore your data. A complete plan should include different types of scenarios that could happen in your area.

For those involved in Healthcare, creating a contingency plan is not optional. Should you have a disaster and are not prepared you can be fined! The Office for Civil Rights (OCR) considers protecting personal information a civil right and they will enforce this if you have a data breach or a situation where your data is not recoverable.

Think about ransomware, have you included this in your contingency plan?

Depending where you are located, have you included how to respond to a hurricane, tornado, snowstorm, or fire?

Where is your data located and what would happen if you had a toilet overflow or a pipe burst?

In light of the recent tragedies have you included a section on workplace violence?

How to create a Contingency plan:

Conduct a thorough HIPAA Risk Assessment. Understand and analyze what type of risks you are vulnerable to. This includes where you are located and what type of computer network that you utilize.
Create a diagram of how your network is configured. This will help you to determine the best method to protect and restore your data from a backup.
Implement a risk management plan that outlines what you have in place and what you will need in the future if it is not possible at the moment. Of course, you will need a timeline if you will be adding to your plan.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

Healthcare Cyber Attacks went up almost 90% in 2017

Suze Shaffer February 15, 2018February 2, 2024

By Aris Medical Solutions

There were 132 reported breaches under investigation from Health and Human Services’ (HHS) Office for Civil Rights (OCR) in 2017 related to Hacking/IT Incident. As you review the report you can see how many were related to email and desktop computers.

Click here to see a list of current data breaches: OCR breach portal

So how does this happen? More than likely it has been caused by an unsuspecting employee. Healthcare is typically targeted with ransomware through social engineering. Practices need to be vigilant in educating their staff to be extremely careful when it comes to clicking on emails or surfing the web with their work computers. That is why we always recommend work computers be used exclusively for work. Plus, personal email addresses should never be utilized to communicate with patients or vendors for a number of reasons, this being just one!

There were many server attacks as well. This can happen in the same manner, especially when someone is logged in with administrative rights when they should be logged in as a user instead.

When it comes to cloud storage or cloud based EHRs, these too can be hacked although it is not as common. Most of the time this is caused by a misconfiguration in the network.

What can you do to prevent this from happening to you?

First of all, conduct a full HIPAA Security Risk Analysis, you need to know where your data is in order to create a Risk Management Plan to protect your organization.
Secondly, continual education on new threats to inform your employees how to be diligent.
Most of all, make sure your IT professional is a network security specialist. Doing your own network security is not longer an option, you must utilize a professional to ensure your network is secure. This includes your websites and cloud services.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Automation, Education, and Support”

Office for Civil Rights (OCR) Self Reporting – Should you do it?

Suze Shaffer October 18, 2017February 1, 2024

By Aris Medical Solutions

If you have a minor breach (under 500 records) you are required to self report this breach within 60 days after the end of the calendar year in which the disclosure occurred. If you report it, you run the risk of being investigated. So many times I hear organizations say… why would I “report” myself, that would be insane! If you do not report it and it is discovered at a later date, the fines will be increased and they will investigate heavily to determine if you have concealed any other breaches. So, the answer is YES; you should self report.

Understand that the different agencies like the Office for Civil RIghts (OCR) who enforces HIPAA, Federal Trade Commission (FTC), Department of Justice (DOJ), and Centers for Medicare and Medicaid (CMS) more than likely communicate with each other. If you are audited or investigated by one agency, they are looking at your organization as a whole and may report their findings to other agencies. In one scenario that we recently were made aware of the organization was expecting an investigation from the Office for Civil Rights and the Department of Justice showed up! These agencies can decide how and what to investigate based on the information they have received.

The best way to protect your organization is to make sure you have a complete and thorough risk analysis. This will uncover potential vulnerabilities and give you the opportunity to mitigate them BEFORE something happens. Next, make sure you have a risk management plan that dates/documents what you have implemented/corrected based on your risk analysis. Policies, procedures, and documentation are the foundation of all organizations. Your employees need clear and concise procedures so they understand what they need to do. This always insulates you from misunderstanding. Above all, it demonstrates your compliance efforts!

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Partnership, Education, and Support”

1557 Discrimination Law – is your practice at risk?

Suze Shaffer April 3, 2017February 2, 2024

By Aris Medical Solutions

Section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA). The law prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. Section 1557 builds on longstanding and familiar Federal civil rights laws: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975. Section 1557 extends nondiscrimination protections to individuals participating in:

Any health program or activity any part of which received funding from HHS
Any health program or activity that HHS itself administers
Health Insurance Marketplaces and all plans offered by issuers that participate in those Marketplaces.

Section 1557 has been in effect since its enactment in 2010 and the HHS Office for Civil Rights has been enforcing the provision since it was enacted.
This provision goes much further than most practices are aware of including the fact this rule became effective July 18, 2016.

Take steps to ensure 1557 has been addressed:
Assign a Civil Rights Coordinator;
Revise your policies and procedures;
Incorporate a general assessment evaluation;
Review the patient intake process;
Track all requests for auxiliary aids and services;
Monitor performance of interpreter services to ensure effective communication;
Review your complaint process;
Post a Notice of Nondiscrimination;
Post a Nondiscrimination Statement; and
Conduct mandatory training for all staff.

Title II of the Americans with Disabilities Act of 1990 (Title II), Section 504 of the Rehabilitation Act of 1973 (Section 504) and Section 1557 of the Affordable Care Act of 2010 (Section 1557) requires an entity to take steps to ensure communication with individuals with disabilities is as effective as communication with others through the use of appropriate auxiliary aids and services. This includes people with as well as language barriers.

OCR has modified the notice requirement in § 92.8 to exclude publications and significant communications that are small in size from the requirement to post all of the content specified in § 92.8; instead, covered entities will be required to post only a shorter nondiscrimination statement in such communications and publications, along with a limited number of taglines. OCR also is translating a sample nondiscrimination statement that covered entities may use in fulfilling this obligation.
In addition, with respect to the obligation in § 92.8 to post taglines in at least the top 15 languages spoken nationally by persons with limited English proficiency, OCR has replaced the national threshold with a threshold requiring taglines in at least the top 15 languages spoken by limited English proficient populations statewide.

Samples can be downloaded here:
https://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Partnership, Education, and Support”