HHS’ Office for Civil Rights Settles HIPAA Ransomware Security Rule Investigation with BST & Co. CPAs, LLP

Settlement Marks OCR’s 15th Ransomware Enforcement Action and 10th Enforcement Action in OCR’s Risk Analysis Initiative

Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a settlement with BST & Co. CPAs, LLP (“BST”), a New York public accounting, business advisory, and management consulting firm, concerning a potential violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule. BST is a HIPAA business associate and receives financial information that also contains protected health information (PHI) from a HIPAA covered entity.

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 – such as BST – must follow to protect the privacy and security of PHI. The HIPAA Security Rule establishes national standards to protect and secure our health care system by requiring administrative, physical, and technical safeguards to ensure the confidentiality, integrity, availability, and security of electronic protected health information (ePHI). The Risk Analysis provision requires regulated organizations (covered entities and business associates) to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI held by those organizations.

“A HIPAA risk analysis is essential for identifying where ePHI is stored and what security measures are needed to protect it,” said OCR Director Paula M. Stannard. “Completing an accurate and thorough risk analysis that informs a risk management plan is a foundational step to mitigate or prevent cyberattacks and breaches.”

The settlement resolves an investigation of BST that OCR initiated after receiving a breach report that BST filed on February 16, 2020. BST reported that on December 7, 2019, BST discovered that part of its network was infected with ransomware, impacting the PHI of its covered entity client. OCR’s investigation determined that BST had failed to conduct an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI held by BST.

Under the terms of the resolution agreement, BST agreed to implement a corrective action plan that will be monitored by OCR for two years and paid $175,000 to OCR. Under the corrective action plan, BST has agreed to take a number of steps to ensure compliance with the HIPAA Security Rule and protect the security of ePHI, including:

• Conduct an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the confidentiality, integrity, and availability of its ePHI;
• Develop and implement a risk management plan to address and mitigate security risks and vulnerabilities identified in its risk analysis;
• Develop, maintain, and revise, as necessary, written policies and procedures to comply with the HIPAA Privacy and Security Rules; and
• Augment its existing HIPAA and security training program and provide annual training for all workforce members to whom the HIPAA policies and procedures apply, including workforce members with access to PHI.

OCR recommends that HIPAA covered health care providers, health plans, health care clearinghouses, and business associates implement the following steps to mitigate or prevent cyber-threats:

• Identify where ePHI is located in the organization, including how ePHI enters, flows through, and leaves the organization’s information systems.
• Periodically conduct, and update as needed, a risk analysis and develop and implement risk management measures to address identified risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI.
• Ensure audit controls are in place to record and examine information system activity.
• Implement regular review of information system activity.
• Utilize mechanisms to authenticate users seeking access to ePHI.
• Encrypt ePHI in transit and at rest to guard against unauthorized access to ePHI when appropriate.
• Incorporate lessons learned from incidents into the organization’s overall security management process.
• Provide workforce members with regular HIPAA training that is specific to the organization and to the workforce members’ respective job duties.

The resolution agreement and corrective action plan may be found at https://www.hhs.gov/sites/default/files/hhs-ocr-bst-hipaa-settlement.pdf.

OCR is committed to enforcing the HIPAA Rules that protect the privacy and security of individuals’ protected health information. Please see OCR’s guidance and webinar on the HIPAA Security Rule Risk Analysis requirement.

If you believe that your or another person’s health information privacy or civil rights have been violated, you can file a complaint with OCR at https://www.hhs.gov/ocr/complaints/index.html.

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