The University of Mississippi Medical Center (UMMC) has signed a resolution agreement with the U.S. Department of Health and Human Services Office for Civil Rights (OCR) following an investigation of a data breach of unsecured protected health information (ePHI) that occurred in 2013.
As part of the settlement due to multiple alleged violations of the Health Insurance Portability and Accountability Act (HIPAA), UMMC will pay a penalty of $2.75 million and adopt a corrective action plan designed to assure future compliance with HIPAA Privacy, Security and Breach Notification Rules, according to an OCR announcement.
OCR’s investigation of UMMC was triggered by a breach of unsecured ePHI affecting approximately 10,000 individuals. “During the investigation, OCR determined that UMMC was aware of risks and vulnerabilities to its systems as far back as April 2005, yet no significant risk management activity occurred until after the breach, due largely to organizational deficiencies and insufficient institutional oversight,” the agency stated in the announcement.
“In addition to identifying risks and vulnerabilities to their ePHI, entities must also implement reasonable and appropriate safeguards to address them within an appropriate time frame,” OCR Director Jocelyn Samuels said in a prepared statement. “We at OCR remain particularly concerned with unaddressed risks that may lead to impermissible access to ePHI.”
University of Mississippi is the state’s sole public academic health science center with education and research functions. In addition it provides patient care in four specialized hospitals on the Jackson campus and at clinics throughout Jackson and the state. Its designated health care component, UMMC, includes University Hospital, the site of the breach in this case, located on the main UMMC campus in Jackson.
On March 21, 2013, OCR was notified of a breach after UMMC’s privacy officer discovered that a password-protected laptop was missing from UMMC’s Medical Intensive Care Unit (MICU). According to HHS OCR, UMMC's investigation concluded that it had likely been stolen by a visitor to the MICU who had inquired about borrowing one of the laptops. OCR’s investigation revealed that ePHI stored on a UMMC network drive was vulnerable to unauthorized access via UMMC’s wireless network because users could access an active directory containing 67,000 files after entering a generic username and password. The directory included 328 files containing the ePHI of an estimated 10,000 patients dating back to 2008.
OCR also stated that during its investigation into the data breaches the agency found that UMMC failed to implement its policies and procedures to prevent, detect, contain, and correct security violations and failed to implement physical safeguards for all workstations that access ePHI to restrict access to authorized users. In addition, OCR cited UMMC for failing to assign a unique user name and/or number for identifying and tracking user identity in information systems containing ePHI as well as failing to notify each individual whose unsecured ePHI was reasonably believed to have been accessed, acquired, used, or disclosed as a result of the breach.