Children's Hospital Colorado Notice of Final Determination

U.S. Department of Health and Human Services
Office for Civil Rights
Office of the Secretary
Hubert H. Humphrey Building 
200 Independence Avenue, S.W. 
Washington, D.C. 20201 
http://www.hhs.gov/ocr

September 26, 2024

VIA PERSONAL SERVICE TO Registered Agent:
Susan Hallenberger
Children’s Hospital Colorado
13123 East 16^th Avenue, B545
Aurora, Colorado 80045

VIA PERSONAL SERVICE TO Chief Executive Officer:
Jena Hausmann
Children’s Hospital Colorado
13123 East 16^th Avenue
Aurora, Colorado 80045

VIA EMAIL TO Privacy Officer:
Janell Briggs
13123 East 16^th Avenue
Aurora, Colorado 80045
Janell.Briggs@Childrenscolorado.org

VIA EMAIL TO Legal Counsel:
Iliana Peters Polsinelli
1401 Eye Street NW, Suite 800
Washington, D.C. 20005
ipeters@polsinelli.com

Iliana Peters, Esq.
Polsinelli
1401 Eye Street NW, Suite 800
Washington, D.C. 20005
ipeters@polsinelli.com

Janell Briggs
13123 East 16^th Avenue
Aurora, Colorado 80045
Janell.Briggs@Childrenscolorado.org

Re:Children’s Hospital Colorado
OCR Transaction Numbers: 17-281691 and 20-389876

Notice of Final Determination

Dear  Iliana Peters:
Janell Briggs:

Pursuant to the authority delegated by the Secretary of the United States Department of Health and Human Services (HHS) to the Director of the Office for Civil Rights (OCR), I am writing to inform you that the civil money penalty (CMP) of $548,265.00 against Children’s Hospital Colorado ("CHC") is final. This letter also contains instructions for CHC to make payment of the CMP amount.

I. CHC is Waiving the Right to Request a Hearing Before an Administrative Law Judge and Petition for Judicial Review

By letter dated June 11, 2024, OCR issued CHC a Notice of Proposed Determination (attached hereto), informing CHC that OCR was proposing to impose a CMP in the amount of $548,265.00 based on the findings of the facts of noncompliance specified in the letter. The Notice of Proposed Determination notified CHC of its right to request a hearing on the proposed CMP within ninety (90) days of the date of receipt of the letter and provided instructions on requesting a hearing with the Departmental Appeals Board. The Notice of Proposed Determination further advised that failure to request a hearing within this time period could result in the imposition of the proposed CMP without a hearing under 45 C.F.R. § 160.504 or the right of appeal under 45 C.F.R. § 160.548. CHC received the Notice of Proposed Determination on June 20, 2024, when it was delivered by a duly registered process server to Linda Michael, Vice President, Chief Compliance Officer, who confirmed she was expressly authorized to accept process for CHC’s Chief Executive Officer, Jena Hausmann, and CHC’s Registered Agent, Susan Hallenberger. CHC also received the Notice of Proposed Determination on June 18, 2024, when OCR emailed it to CHC’s attorney, Iliana Peters, and CHC’s Privacy Officer, Janell Briggs.

By letter dated September 9, 2024, sent via email to OCR, CHC’s counsel advised that CHC was not contesting the imposition of a CMP. OCR also notes that the 90-day time frame to request a hearing with the Departmental Appeals Board has passed without CHC requesting a hearing. Accordingly, by operation of CHC’s waiver of its procedural rights to challenge the CMP under 45 C.F.R. Part 160 Subparts D and E and 42 U.S.C. § 1320a-7a, the CMP referenced above is now final. Therefore, pursuant to the authority delegated by the Secretary of HHS to the Director of OCR, I am authorized to impose the CMP against CHC in the full amount of $548,265.000, as set forth in the Notice of Proposed Determination.

II. No Right of Appeal

CHC has no right to appeal the imposition of the CMP under 45 C.F.R. § 160.548 since CHC chose to waive its right to appeal OCR’s proposed determination and its right to request a hearing.

III. Instructions for Payment of the CMP Amount

Payment of the full and aggregate amount of $548,265.00 is due upon CHC’s receipt of this Notice of Final Determination. Payment can be made in accordance with the instructions on enclosed with this Notice.

IV. Consequences of Nonpayment

In the event that payment is not received upon CHC’s receipt of this Notice of Final Determination, a civil action may be brought in the United States District Court to recover the amount of the penalty.

V. The Legal Basis for This Action

This action is being taken under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), § 262(a), Pub.L. 104-191, 110 Stat. 1936, as amended, codified at 42 U.S.C. § 1320d-5, and under the enforcement regulations at 45 C.F.R. Part 160, subpart D. The Secretary of HHS is authorized to impose CMPs (subject to the limitations at 42 U.S.C. § 1320d-5(b)) against any covered entity, as described at 42 U.S.C. § 1320d-l(a), that violates a provision of Part C (Administrative Simplification) of Title XI of the Social Security Act. See 42 U.S.C. § 1320d- 5(a), as amended. This authority extends to violations of the regulations commonly known as the Privacy Rule promulgated at 45 C.F.R. Part 160 and subparts A and E of Part 164, pursuant to Section 264(c) of HIPAA. The Secretary has delegated enforcement responsibility for the Privacy Rule to the Director of OCR. See Office for Civil Rights; Statement of Delegation of Authority, 65 Fed. Reg. 82381 (Dec. 28, 2000).

If you have any questions concerning this letter, please contact Emily Crabbe, OCR Senior Advisor, at (404) 562-7878.

Sincerely,
/s/
Melanie Fontes Rainer Director
Office for Civil Rights
U.S. Department of Health and Human Services

Enclosed:
Payment Instructions
Notice of Proposed Determination (June 11, 2024)