HIPAA 101: Are Your Admin Passwords Vulnerable? Are You Changing Them Periodically?

On September 23, 2020, CHSPSC LLC, (“CHSPSC”) agreed to pay $2,300,000 to the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) and to adopt a corrective action plan to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules related to a breach affecting over six million people. CHSPSC provides a variety of business associate services, including IT and health information management, to hospitals and physician clinics indirectly owned by Community Health Systems, Inc., in Franklin, Tennessee.

In April 2014, the Federal Bureau of Investigation (FBI) notified CHSPSC that it had traced a cyberhacking group’s advanced persistent threat to CHSPSC’s information system. Despite this notice, the hackers continued to access and exfiltrate the protected health information (PHI) of 6,121,158 individuals until August 2014. The hackers used compromised administrative credentials to remotely access CHSPSC’s information system through its virtual private network (VPN).

OCR’s investigation found longstanding, systemic noncompliance with the HIPAA Security Rule including failure to conduct a risk analysis, and failures to implement information system activity review, security incident procedures, and access controls.

“The health care industry is a known target for hackers and cyberthieves. The failure to implement the security protections required by the HIPAA Rules, especially after being notified by the FBI of a potential breach, is inexcusable,” said OCR Director Roger Severino.

In addition to the monetary settlement, CHSPSC has agreed to a robust corrective action plan that includes two years of monitoring and the following:
• Review and revise its policies and procedures regarding technical access controls for any and all software applications and network or server equipment and systems to ensure authorized access is limited to the minimum amount necessary and to prevent impermissible access and disclosure of ePHI.

• Review and revise its policies and procedures regarding information system activity review for the regular review of audit logs, access reports, and security incident tracking reports to monitor and respond to suspicious events.

• Review and revise its policies and procedures regarding Security Incident Procedures and Response and Reporting to identify and respond to a known security incident, mitigate, to the extent practicable, the harmful effects of the security incident, and document the security incident and its outcome.

• Review and revise its policies and procedures regarding password management, specifically relating to password strength and safeguarding.

The full resolution agreement and corrective action plan may be found here.

Contact us at Kentucky REC with your HIPAA questions. We’re here to help and are available at 859-323-3090.