St. Joseph Health (SJH) has agreed to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules following the report that files containing electronic protected health information (ePHI) were publicly accessible through internet search engines from 2011 until 2012. SJH, a nonprofit integrated Catholic health care delivery system sponsored by the St. Joseph Health Ministry, will pay a settlement amount of $2,140,500 and adopt a comprehensive corrective action plan. SJH’s range of services includes 14 acute care hospitals, home health agencies, hospice care, outpatient services, skilled nursing facilities, community clinics and physician organizations throughout California and in parts of Texas and New Mexico.
On February 14, 2012, SJH reported to the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) that certain files it created for its participation in the meaningful use program, which contained ePHI, were publicly accessible on the internet from February 1, 2011, until February 13, 2012, via Google and possibly other internet search engines. The server SJH purchased to store the files included a file sharing application whose default settings allowed anyone with an internet connection to access them. Upon implementation of this server and the file sharing application, SJH did not examine or modify it. As a result, the public had unrestricted access to PDF files containing the ePHI of 31,800 individuals, including patient names, health statuses, diagnoses, and demographic information.
OCR’s investigation indicated the following potential violations of the HIPAA Rules:
- From February 1, 2011 to February 13, 2012, SJH potentially disclosed the PHI of 31,800 individuals;
- Evidence indicated that SJH failed to conduct an evaluation in response to the environmental and operational changes presented by implementation of a new server for its meaningful use project, thereby compromising the security of ePHI;
- Although SJH hired a number of contractors to assess the risks and vulnerabilities to the confidentiality, integrity and availability of ePHI held by SJH, evidence indicated that this was conducted in a patchwork fashion and did not result in an enterprise-wide risk analysis, as required by the HIPAA Security Rule.
“Entities must not only conduct a comprehensive risk analysis, but must also evaluate and address potential security risks when implementing enterprise changes impacting ePHI,” said OCR Director Jocelyn Samuels. “The HIPAA Security Rule’s specific requirements to address environmental and operational changes are critical for the protection of patient information.”
In addition to the $2,140,500 settlement, SJH 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/sjh.