The Upper San Juan Health Service District d/b/a Pagosa Springs Medical Center (“PSMC”), a critical access hospital in Colorado, has agreed to a $111,400 settlement with the U.S. Department of Health and Human Services Office for Civil Rights (“OCR”) to resolve a complaint alleging that a former PSMC employee continued to have remote access to PSMC’s web-based scheduling calendar because PSMC failed to deactivate the former employee’s username and password following termination of employment. OCR investigated the complaint and discovered that PSMC impermissibly disclosed the protected health information (“PHI”) of 557 patients to the former employee. Moreover, OCR determined that PSMC did not have a Business Associate agreement in place with the vendor of the web-based scheduling calendar.
The Resolution Agreement also includes a two-year Corrective Action Plan. Under the Corrective Action Plan, PSMC must: (i) revise its policies and procedures relating to Business Associates and uses and disclosures of PHI; (ii) submit proposed training materials on the revised policies and procedures for OCR’s review and train workforce members in accordance with the approved training materials; (iii) develop a current Risk Analysis and submit such analysis to OCR for review; and (iv) upon OCR’s approval of the Risk Analysis, provide OCR with a risk management plan that addresses and mitigates the security risks and vulnerabilities identified in the Risk Analysis and documentation that the risk management plan is being implemented.
The Resolution Agreement and Corrective Action Plan are available here.
HIPAA requires covered entities and business associates to terminate a workforce member’s access to all systems and databases containing PHI upon the date the workforce member’s employment, or other arrangement with the entity, ends. The PSMC settlement serves as a reminder that the electronic health record is not the only database for which access must be terminated. HIPAA entities should develop a checklist that identifies all systems and databases containing PHI to ensure all access to PHI is terminated upon a workforce member’s separation from the entity.