HHS Office for Civil Rights Settles 9th Ransomware Investigation with Virtual Private Network Solutions

Settlement marks OCR’s 3rd enforcement action in OCR's Risk Analysis Initiative

Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a $90,000 settlement with Virtual Private Network Solutions, LLC (VPN Solutions), a Virginia business associate that provides data hosting and cloud services to covered entities (health plans, health care clearinghouses, and most health care providers) and business associates, for a potential violation under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule. OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules, which set forth the requirements that covered entities (health plans, health care clearinghouses, and most health care providers), and business associates must follow to protect the privacy and security of protected health information (PHI). The HIPAA Security Rule establishes national standards to protect and secure our health care system by requiring administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of electronic PHI (ePHI). The settlement resolves an investigation concerning a ransomware attack on VPN Solutions’s information system.

“An accurate and thorough risk analysis is foundational to both HIPAA Security Rule compliance and protecting health information from cyberattacks.” said OCR Director Melanie Fontes Rainer. “Failure to conduct a risk analysis leaves health care entities exposed to future hacking and ransomware attacks.  OCR urges health care entities to take the necessary steps to reduce risks and vulnerabilities and safeguard protected health information.”

Ransomware and hacking are the primary cyberthreats in health care. Ransomware is a type of malware (malicious software) designed to deny access to a user’s data, usually by encrypting the data with a key known only to the hacker who deployed the malware, until a ransom is paid. Since 2018, there has been a 264% increase in large breaches reported to OCR involving ransomware attacks. The settlement also marks the third enforcement action in OCR's Risk Analysis Initiative. This enforcement initiative was created to focus select investigations on compliance with the HIPAA Security Rule Risk Analysis provision, a key Security Rule requirement, and the foundation for effective cybersecurity and the protection of ePHI; to increase the number of completed investigations; and to highlight the need for more attention and better compliance with this Security Rule requirement.

In December of 2021, OCR received a breach report concerning a ransomware incident that impacted portions of the VPN Solutions server infrastructure. VPN Solutions filed the breach report on behalf of twelve covered entities, which had delegated their responsibility to report the breach to VPN Solutions. VPN Solutions reported that it became aware of the attack on October 31, 2021.  The initial report indicated that the data encrypted included names, addresses, dates of birth, driver’s license information, social security numbers, other identifiers, claim information, bank account numbers, other financial information, diagnoses/conditions, lab results, medications, and other treatment information. OCR's investigation determined that VPN Solutions had failed to conduct a compliant risk analysis to determine the potential risks and vulnerabilities to ePHI in their system.  The settlement resolves OCR's investigation concerning VPN Solutions and this ransomware attack. Under the terms of the settlement agreement, OCR will monitor VPN Solutions for one year to ensure compliance with HIPAA. In addition, VPN Solutions has agreed to pay $90,000 to OCR and to implement a corrective action plan, which identifies the steps that VPN Solutions will take to resolve potential violations of the HIPAA Privacy and Security Rules and protect the security of ePHI, including:

• Conducting an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the confidentiality, integrity, and availability of its ePHI;
• Implementing a risk management plan to address and mitigate security risks and vulnerabilities identified in their risk analysis;
• Developing, maintaining, and revising, as necessary, its written policies and procedures to comply with the HIPAA Rules; and
• Conducting a breach risk assessment of the October 31, 2021, breach and providing evidence to OCR that all covered entities affected by the breach have been notified of the breach and the identity of individuals affected by the breach.

The resolution agreement and corrective action plan may be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/vpns-ra-cap/index.html

OCR recommends that health care providers, health plans, health care clearinghouses, and business associates that are covered by HIPAA take the following steps to mitigate or prevent cyber-threats:

• Review all vendor and contractor relationships to ensure business associate agreements are in place as appropriate and address breach/security incident obligations.
• Integrate risk analysis and risk management into business processes regularly.
• Ensure audit controls are in place to record and examine information system activity.
• Implement regular review of information system activity.
• Utilize multi-factor authentication to ensure only authorized users are accessing ePHI.
• Encrypt ePHI to guard against unauthorized access to ePHI.
• Incorporate lessons learned from incidents into the overall security management process.
• Provide training specific to organization and job responsibilities and on regular basis; reinforce workforce members' critical role in protecting privacy and security.

The HHS Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information may be found at: https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf

OCR is committed to enforcing the HIPAA Rules that protect the privacy and security of peoples' health information. Guidance about the Privacy Rule, Security Rule, and Breach Notification Rules can also be found on OCR's website.

If you believe that your or another person's health information privacy or civil rights have been violated, you can file a complaint with OCR at https://www.hhs.gov/ocr/complaints/index.html.

Follow HHS OCR on X (formerly Twitter) at @HHSOCR.