HHS’ Office for Civil Rights Settles HIPAA Ransomware Investigation with Syracuse ASC

Settlement Marks OCR’s 14^th Ransomware Enforcement Action

Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a settlement with Syracuse ASC, LLC doing business as Specialty Surgery Center of Central New York, for potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security and Breach Notification Rules. Syracuse ASC is a single-facility, ambulatory surgery center located in Liverpool, New York that provides ophthalmic and ENT surgical services and pain management procedures to patients.

OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules (the HIPAA 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 system by requiring administrative, physical, and technical safeguards to ensure the confidentiality, integrity, availability, and security of electronic PHI (ePHI). The Risk Analysis provision of the Security Rule requires a covered entity or business associate to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI held by that organization. The Breach Notification Rule requires HIPAA covered entities and their business associates to provide notification following a breach of unsecured PHI.

“Conducting a thorough HIPAA-compliant risk analysis (and developing and implementing risk management measures to address any identified risks and vulnerabilities) is even more necessary as sophisticated cyberattacks increase, said OCR Director Paula M. Stannard. “HIPAA covered entities and business associates make themselves soft targets for cyberattacks if they fail to implement the HIPAA Security Rule requirements.”

The settlement resolves an OCR investigation concerning a ransomware breach of ePHI that affected 24,891 individuals. OCR initiated the investigation in October 2021 after Syracuse ASC reported to HHS that an unauthorized individual had accessed its network in March 2021. Further investigation revealed that Syracuse ASC was affected by a ransomware attack involving the PYSA ransomware variant, which is a cross-platform cyber weapon known to target the healthcare industry. OCR’s investigation found that Syracuse ASC never conducted an accurate and thorough risk analysis to determine the risks and vulnerabilities to the ePHI it held. OCR also found that Syracuse ASC failed to timely notify affected individuals and the Secretary of the breach.

Under the terms of the resolution agreement, Syracuse ASC agreed to implement a corrective action plan that OCR will monitor for 2 years and paid $250,000 to OCR. Under the corrective action plan, Syracuse ASC committed to take steps to ensure compliance with the HIPAA Rules and protect the security of ePHI, including:

• Conducting an accurate and thorough assessment of the potential security risks and vulnerabilities to the confidentiality, integrity, and availability of its ePHI;
• Developing and implementing a risk management plan to address and mitigate security risks and vulnerabilities identified in its risk analysis;
• Reviewing, and to the extent necessary, revising, certain written policies and procedures to comply with the HIPAA Rules; and
• Providing annual training for workforce members on its written HIPAA policies and procedures.

OCR recommends that HIPAA-covered health care providers, health plans, clearinghouses, and business associates implement the following steps to or prevent or mitigate 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 a risk management plan 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 reviews of information system activity.
• Implement procedures 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.

Covered entities must comply with breach notification obligations under the HIPAA Breach Notification Rule.  In submitting a notice of a breach of unsecured PHI to the HHS Secretary, covered entities must use the HHS Breach Portal.

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

OCR is committed to enforcing the HIPAA Rules that protect the privacy and security of individuals’ protected health information. Guidance about the HIPAA Privacy Rule, Security Rule, and Breach Notification Rule, and the Security Rule’s Risk Analysis requirement, can also be found on OCR’s website.

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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