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Compliance Catastrophes: Improper Access of PHI by Staff

April 24, 2024

It’s hump day! As we get through this middle bump of the week, we’re still rolling our series, Compliance Catastrophes; real-ish world examples of nightmare scenarios! 

Today, we’re looking at you, healthcare workers and Business Associates! We know you do amazing work when taking care of patients, but keeping data secure is a part of building an awesome practice or business environment. 

When given the keys to keep Protected Health Information (PHI) safe, it doesn’t mean to open the treasure chest of data! When working in this field, you’re around a lot of sensitive information, and it’s vital to uphold your commitment to patients by keeping it confidential! 

We know it’s not all healthcare workers or their associates, but more people break this rule than you’d expect. 

We’re getting scientific! There was a recent study that highlighted over 400 employees inappropriately accessing PHI at a hospital, and many only stopped accessing unauthorized PHI due to being warned they were caught by email.  

It shouldn’t take being caught to change bad behavior! You know the drill – improperly accessing PHI is a breach of trust. 

But just to be safe, let’s see an example of what you should not do. Now, joining us today, you guessed it, is our unlucky friend, Catastrophe Cathy. 

PHI Peeking

Cathy was at the front desk when a familiar face showed up for an appointment. An old friend from high school that she hasn’t seen in years! 

They chat for a little bit, and Cathy can’t help but wonder what brought this friend in. 

When she’s closing up, she can’t ignore the voice in the back of her head to go look. She falls for the temptation and searches for her friend’s medical information, curious about what brought her old friend into the practice. 

As she’s reading about her old friend, another employee notices what she’s doing. Cathy is embarrassed and ashamed, as well as she should be! She was breaching her old friend’s PHI. That information is strictly confidential, no matter how close they used to be. 

Real Life: Real Fines

You might think that a situation like this could never happen to you, but it happens often and there are severe consequences. 

Last year, the OCR fined Yakima Valley Memorial Hospital in Washington State due to some snooping security guards. Curiosity didn’t kill the cat, but did leave it with a hefty fine! Over 400 patients’ records were looked at and the hospital was charged with a pretty expensive bill: $240,000! 

To avoid snooping breaches, make sure all staff are properly trained on their roles and responsibilities. Access controls need to be monitored often, ensuring staff only have access to what pertains to their role. Additionally, make sure logs are reviewed, keeping your eyes open for any suspicious activity.  

We all deserve our health information to be secure, and healthcare workers and business associates are at the front lines of keeping it confidential. To learn more about common compliance catastrophes, email us at info@abyde.com and stay tuned for the next in our series on our social media! 

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NextThe Brief History of HIPAA: How We Got Here and Why it MattersNext

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September 21, 2026 Penelope Schweitzer No comments yet

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August 5, 2026 The latest HIPAA fine is another clear reminder that ransomware attacks are, unfortunately, here to stay in the healthcare industry. A settlement involving the OSF Healthcare System was recently announced by the Office for Civil Rights (OCR). As an enterprise healthcare provider in the midwest, the organization serves 174 locations, including 16 hospitals – a prime target for a ransomware attack.    So, what happened?  In April 2021, OSF discovered that they joined the unlucky club of ransomware victims when a malicious actor deployed Nephilim, a ransomware strain made to target larger organizations. Once the ransomware infected OSF systems, the hacker demanded payment or patient Protected Health Information (PHI) would be leaked online. In this attack, sensitive information like financial account information, driver’s license numbers, medical record numbers, and more, were all exposed. Over 53,000 patient records were exposed in this attack.  When ransomware attacks in healthcare have soared 278% in recent years, it’s more of a when then an if your organization doesn’t have the right safeguards in place.  While the breach was discovered in April, OSF healthcare reported the breach to the OCR in October. The OCR took it from there, digging into what precautions (or lack thereof) let this happen.  What did the OCR discover? If you’ve read any of our other fine breakdowns, you already know where this is going: another missing Security Risk Analysis (SRA).  The SRA is a required document every HIPAA-regulated entity (ie: every practice and their Business Associates that handle patient information) needs to complete. The SRA is a thorough review of the physical, technical, and administrative safeguards in place to prevent PHI ending up in the wrong hands. While the OCR didn’t specify exactly how the ransomware got into OSF’s system, a technical safeguard vulnerability was very likely the entry point. A proactive SRA could have flagged that gap before it turned into a major breach. In addition to missing this required documentation, OSF also took too long to report the breach to the OCR and notify affected patients. This is a direct violation of the Breach Notification Rule, which requires organizations to notify patients within 60 days of a discovered breach. Moreover, since the breach impacted more than 500 patients, OSF was also required to report this breach to the OCR within 2 months as well. Time is of the essence in every component of a breach, from securing systems to ensuring affected parties are aware to protect themselves and an over five month delay was unacceptable in the eyes of the OCR.    What was the result?  OSF’s settlement tops the list as the largest fine of the year, coming in at $552,250, plus government monitoring for the next two years.  It’s very important to note that this breach occurred in 2021, meaning that over five years were spent from the initial breach, to investigations, to the public press releases. Also, the average cost of a healthcare breach is over 7 million dollars –  from implementing secure systems, notifying patients, legal fees, and more. The Takeaway While the settlement payment and Corrective Action Plan (CAP) are just the cherries on top, this experience was a tremendous cost of time, money, and resources, highlighting the importance of making sure everything is secure before a situation occurs.  So, when was the last time you looked at your SRA? It’s time to seriously analyze your current compliance posture. Ransomware groups don’t check whether you’re a small dental office or a 16-hospital health system before they attack, they check whether the door was left open. Time and again, OCR’s findings come back to the same root cause: organizations can’t secure what they haven’t even identified as a problem. Looking to review your current compliance standings? Meet with our team of experts for a complimentary educational consultation. 

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