Hospital Revises Email Distribution as a Result of a Disclosure to Persons Without a "Need to Know"
Hospital Revises Email Distribution as a Result of a Disclosure to Persons Without a "Need to Know"
Covered Entity: General Hospital
Issue: Impermissible Use and Disclosure
A complainant, who was both a patient and an employee of the
hospital, alleged that her protected health information (PHI) was
impermissibly disclosed to her supervisor. OCR’s investigation revealed
that: the hospital distributed an Operating Room (OR) schedule to
employees via email; the hospital’s OR schedule contained information
about the complainant’s upcoming surgery. While the Privacy Rule may
permit the disclosure of an OR schedule containing PHI, in this case, a
hospital employee shared the OR scheduled with the complainant’s
supervisor, who was not part of the employee's treatment team, and did
not need the information for payment, health care operations, or other
permissible purposes. The hospital disciplined and retrained the
employee who made the impermissible disclosure. Additionally, in order
to prevent similar incidents, the hospital undertook a complete review
of the distribution of the OR schedule. As a result of this review, the
hospital revised the distribution of the OR schedule, limiting it to
those who have “a need to know.”
| Issued by: Office for Civil Rights (OCR) What if a HIPAA covered entity (or business associate) uses a CSP to maintain ePHI without first executing a business associate agreement with that CSP? Answer: If a covered entity (or business associate) uses a CSP to maintain (e.g., to process or store) electronic protected health information (ePHI) without entering into a BAA with the CSP, the covered entity (or business associate) is in violation of the HIPAA Rules. 45 C.F.R §§164.308(b)(1) and §164.502(e). OCR has entered into a resolution agreement and corrective action plan with a covered entity that OCR determined ...read more |
| Mental Health Center Corrects Process for Providing Notice of Privacy Practices Covered Entity: Outpatient Facility Issue: Notice A mental health center did not provide a notice of privacy practices (notice) to a father or his minor daughter, a patient at the center. In response to OCR’s investigation, the mental health center acknowledged that it had not provided the complainant and his daughter with a notice prior to her mental health evaluation. To resolve this matter, the mental health center revised its intake assessment policy and procedures to specify that the notice will be provided and the clinician will attempt to ...read more |
| Health Plan Corrects Computer Flaw that Caused Mailing of EOBs to Wrong Persons Covered Entity: Health Plans Issue: Safeguards A national health maintenance organization sent explanation of benefits (EOB) by mail to a complainant's unauthorized family member. OCR's investigation determined that a flaw in the health plan's computer system put the protected health information of approximately 2,000 families at risk of disclosure in violation of the Rule. Among the corrective actions required to resolve this case, OCR required the insurer to correct the flaw in its computer system, review all transactions for a six month period and correct all ...read more |
| State Hospital Sanctions Employees for Disclosing Patient's PHI Covered Entity: Health Care Provider / General Hospital Issue: Impermissible Disclosure A nurse and an orderly at a state hospital discussed the HIV/AIDS status of a patient and the patient's spouse within earshot of other patients without making reasonable efforts to prevent the disclosure. Upon learning of the incident, the hospital placed both employees on leave; the orderly resigned his employment shortly thereafter. Among other actions taken to satisfactorily resolve this matter, the hospital took further disciplinary action with the nurse, which included: documenting the employee record with a memo of ...read more |
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