?What. am; DEPARTMENT OF HEALTH 8: SERVICES OFFICE OF THE SECRETARY Voice- (215) 361?4441 TDD - (215) 361-4440 FAX - (215) 861-4431 Office for Civil Region 150 5. Independence Hall West Public Ledger Building, Suite Philadelphla, PA 19106-3499 Reference: 13-15906? Investigator: Alisha Welch Contact Telephone: (215} 861-4439 November 12, 2013 {bli?l .EbliiliC-l Dear gbzrarblm On October 23, 2013, the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received your complaint alleging that the Virginia Department of Veteran Services, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information andfor the Security Standards for the Protection of Electronic Protected Health Information (45 C.F.R. Parts 160 and 164, Subparts A, C, and E, the Privacy and Security Ri?es). Speci?cally, you allege that when you visited the Virginia Department of Veteran Services, patient ?les were left in an opened, unattended ?ling cabinet. This allegation could re?ect violation of45 can. manned).l Thank you for bringing this matter to attention. Your complaint is an integral part of enforcement efforts. OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also Federal civil rights laws which prohibit discrimination in the delivery of health and human services because of race, color, national origin, disability, age, and under certain circumstances, sex and religion A covered entity must maintain reasonable and administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of PHI in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure. 4.5 C.F.R. For example, such safeguards might include shredding documents containing proteoted health information before discarding them, securing medical records with lock and key or pass code, and limiting access to keys or pass codes. We have carefully reviewed your complaint against the Virginia Department of Veteran Services and have determined to resolve this matter informally through the provision of technical I You also raises issues about a billing dispute with Family Care West. After our review of your complaint, we have determined that we do not have jurisdiction to review your billing dispute with Family Care West. assistance to the Virginia Department of Veteran Services. Should OCR receive a similar allegation of noncompliance against the Virginia Department of Veteran Services in the ?tture, OCR may initiate a formal investigation of that matter. - For your informational purposes, OCR has enclosed material regarding the Privacy Rule provisions related to Safeguards. Based on the foregoing, OCR is closing this case without further action, effective the date of this letter. determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR Under the Freedom of Information Act, we may be required to release this letter and other information about this case upon request by the public. In the event OCR receives such a request we will make every effort, as permitted by law, to protect information that identi?es individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Alisha Welch, Investigator, at (215) 861-4439 (Voice) or (215) 861-4439 (TDD). Sincerely, 59W /W.J/wr? Barbara J. Hollan Regional Manager Enclosure: Reasonable Safeguards puma 11?, cf DEPARTMENT OF HEALTH 8: HUMAN SERVICES OFFICE OF THE SECRETARY g5 Voice- (215) 361-4441 Of?ce for Civil Rights, Region is. TDD - (215) 361-4440 150 5. Independence Hall West FAX (215) 861-4431 Public Ledger Building, Suite 372 Wm Philadelphia, PA 19106-3499 Reference: 13-16906?) Investigator: Alisha Welch Contact Telephone: (215) 861-4439 November 12, 2013 Virginia Department of Veteran Services 11198 Lee Highway, Unit D4 Fairfax, VA 22030 Dear Sir or Madam: On October 23, 2013, the U.S. Department of Health and Human Services (HHS), Of?ce for Civil Rights (OCR), received a complaint alleging that the Virginia Department of Veteran Services, the covered entity, has violated the Federal Standards for Privacy of Individually Identi?able Health Information andfor the Security Standards for the Protection of Electronic Protected Health Information (45 CPR Parts 160 and 164, Subparts A, C, and E, the Privacy and Security Rules). Speci?cally, the complainant alleges that when he visited the Virginia Department of Veteran Services, patient ?les were left in an opened, unattended ?ling cabinet. This allegation could re?ect a violation of 45 C.F.R. OCR enforces the Privacy, Security, and Breach Noti?cation Rules, and also Federal civil rights laws which prohibit discrimination in the delivery of health and human services because of race, color, national origin, disability, age, and under certain circumstances, sex and religion. In this matter, the complainant alleges that the covered entity does not employ reasonable safeguards to prevent impermissible disclosures of protected health information (PI-H). A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of PHI in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure. 45 CPR Pursuant to its authority under 45 C.F.R. 160.304{a) and OCR has determined to resolve this matter informally through the provision of technical assistance to the Virginia Department of Veteran Services. To that end, OCR has enclosed material explaining the Privacy Rule provisions related to Reasonable Safeguards. You are encouraged to review these materials closely and to share them with your staff as part of the Health Insurance Portability and Accountability Act (HIPAA) training you provide to your workforce. You are also encouraged to assess and determine whether there may have been any noncompliance as alleged by the complainant in this matter, and, if so, to take the steps necessary to ensure such noncompliance does not occur in the future. In addition, OCR encourages you to review the facts of this individual?s complaint and provide the individual the appropriate written response swiftly if necessary to comply with the requirements of the Privacy Rule. Should OCR receive a similar allegation of noncompliance against the Virginia Department of Veteran Services in the future, OCR may initiate a formal investigation of that matter. In addition, please note that, after a period of six months has passed, OCR may initiate and conduct a compliance review of the Virginia Department of Veteran Services related to your compliance with the Privacy Rule?s provisions related to Reasonable Safeguards. Based on the foregoing, OCR is closing this case without further action, effective the date of this letter. determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. Under the Freedom of Information Act, we may be required to release this letter and other information about this case upon request by the public. In the event OCR receives such a request, we will make every effort, as permitted by law, to protect information that identi?es individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy. If you have any questions regarding this matter, please contact Alisha Welch, Investigator, at (215) 861-4439 (Voice) or (215) 861-4440 (TDD). Sincerely, Barbara J. Holland Regional Manager Enclosure: Reasonable Safeguards