The settlement highlights that hospitals, physicians, and other covered entities must understand the importance of monitoring the level of access workforce members have to medical and health information. Covered entities must have policies and procedures in place and educate workforce members about only accessing records for necessary and permissible purposes. This settlement resulted from an investigation by OCR after certain celebrity/VIP patients at the UCLA facilities complained that hospital staff, including unauthorized physicians, had inappropriately accessed their health and medical information.
UCLAHS agreed to a Corrective Action Plan for a period of three years under the terms of the Resolution Agreement. The Corrective Action Plan requires UCLAHS to review/update its current HIPAA policies and procedures, conduct follow up workforce training, monitor compliance and submit a monitoring plan, and submit an implementation report and annual reports to OCR. of can be found attached to the Resolution Agreement.
The Resolution Agreement described the events that occurred that lead to the settlement as follows:
On June 5, 2009 and June 30, 2009, HHS began investigations of two separate complaints alleging that the Covered Entity was in violation of the Privacy and/or Security Rules. The investigations indicated that the following conduct occurred (“Covered Conduct”):
(i) During the period from August 31, 2005 to November 16, 2005, numerous Covered Entity workforce members repeatedly and without a permissible reason examined the electronic protected health information of Covered Entity patients, and during the period from January 31, 2008 to February 2, 2008, numerous Covered Entity workforce members repeatedly and without a permissible reason examined the electronic protected health information of a Covered Entity patient.More information and background can be found in the iHealthBeat article, UCLA Health System Agrees to Pay $865K over Privacy Breaches, including a link to a statement on the settlement issued by UCLH Health System.
(ii) During the period 2005-2008, a workforce member of Covered Entity employed in the office of the Director of Nursing repeatedly and without a permissible reason examined the electronic protected health information of many patients.
(iii) During the period 2005-2008, Covered Entity did not provide and/or did not document the provision of necessary and appropriate Privacy and/or Security Rule training for all members of its workforce to carry out their function within the Covered Entity.
(iv) During the period 2005-2008, Covered Entity failed to apply appropriate sanctions and/or document sanctions on workforce members who impermissibly examined electronic protected health information.
(v) During the period from 2005-2009, Covered Entity failed to implement security measures sufficient to reduce the risks of impermissible access to electronic protected health information by unauthorized users to a reasonable and appropriate level.