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                              Danbury Psychiatric Consultants (DPC) Resolution Agreement and Corrective Action Plan


    

    

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Danbury Psychiatric Consultants (DPC) Resolution Agreement and Corrective Action Plan








  
  
    

  
      





**I.  Recitals**

**Parties**.  The Parties to this Resolution Agreement ("Agreement") are:

	The United States Department of Health and Human Services, Office for Civil Rights ("HHS"), which enforces the Federal standards that govern the privacy of individually identifiable health information (45 C.F.R. Part 160 and Subparts A and E of Part 164, the "Privacy Rule"), the Federal standards that govern the security of electronic individually identifiable health information (45 C.F.R. Part 160 and Subparts A and C of Part 164, the "Security Rule"), and the Federal standards for notification in the case of breach of unsecured protected health information (45 C.F.R. Part 160 and Subparts A and D of 45 C.F.R. Part 164, the "Breach Notification Rule").  HHS has the authority to conduct compliance reviews and investigations of complaints alleging violations of the Privacy, Security, and Breach Notification Rules (the "HIPAA Rules") by covered entities and business associates, and covered entities and business associates must cooperate with HHS compliance reviews and investigations.  *See* 45 C.F.R. §§ 160.306(c), 160.308, and 160.310(b).
		Danbury Psychiatry Consultants, LLC (DPC) which is a covered entity as defined at 45 C.F.R. § 160.103, and therefore is required to comply with the HIPAA Rules.
		HHS and DPC shall together be referred to herein as the "Parties."
	**Factual Background and Covered Conduct.**On March 27, 2020, HHS received a complaint against DPC alleging that DPC failed to provide access to the complainant's protected health information (PHI).

HHS' investigation revealed that, on March 24, 2020, the complainant made an access request for her PHI. DPC failed to respond timely to the complainant's access request.  DPC also withheld complainant's access on the basis that the complainant had an outstanding balance and required a signed request or authorization request. DPC failed to provide access to all the complainant's PHI until September 14, 2020, after OCR initiated its investigation.

HHS' investigation indicated that the following covered conduct occurred ("Covered Conduct"):

A. DPC failed to provide timely access to protected health information about the individual in a designated record set (*see*45 C.F.R. § 164.524).

**No Admission**.  This Agreement is not an admission of liability by DPC.
	**No Concession**.  This Agreement is not a concession by HHS that DPC is not in violation of the HIPAA Rules and not liable for civil money penalties.
	**Intention of Parties to Effect Resolution**.  This Agreement is intended to resolve OCR Transaction Number 01-19-378446 and any violations of the HIPAA Rules related to the Covered Conduct specified in paragraph I.2 of this Agreement.  In consideration of the Parties' interest in avoiding the uncertainty, burden, and expense of further investigation and formal proceedings, the Parties agree to resolve this matter according to the Terms and Conditions below.**II.  Terms and Conditions**

**Payment**.  HHS has agreed to accept, and DPC has agreed to pay HHS, the amount of $3,500 ("Resolution Amount").  DPC agrees to pay the Resolution Amount on the Effective Date of this Agreement as defined in paragraph II.14 pursuant to written instructions to be provided by HHS.
	**Corrective Action Plan**.  DPC has entered into and agrees to comply with the Corrective Action Plan ("CAP"), attached as Appendix A, which is incorporated into this Agreement by reference.  If DPC breaches the CAP, and fails to cure the breach as set forth in the CAP, then DPC will be in breach of this Agreement and HHS will not be subject to the Release set forth in paragraph II.8 of this Agreement.
	**Release by HHS**.  In consideration of and conditioned upon DPC's performance of its obligations under this Agreement, HHS releases DPC from any actions it may have against DPC under the HIPAA Rules arising out of or related to the Covered Conduct identified in paragraph I.2 of this Agreement.  HHS does not release DPC from, nor waive any rights, obligations, or causes of action other than those arising out of or related to the Covered Conduct and referred to in this paragraph.  This release does not extend to actions that may be brought under section 1177 of the Social Security Act, 42 U.S.C. § 1320d-6.
	**Agreement by Released Parties**.  DPC shall not contest the validity of its obligation to pay, nor the amount of, the Resolution Amount or any other obligations agreed to under this Agreement.  DPC waives all procedural rights granted under Section 1128A of the Social Security Act (42 U.S.C. § 1320a- 7a) and 45 C.F.R. Part 160 Subpart E, and HHS claims collection regulations at 45 C.F.R. Part 30, including, but not limited to, notice, hearing, and appeal with respect to the Resolution Amount.
	**Binding on Successors**.  This Agreement is binding on DPC and its successors, heirs, transferees, and assigns.
	**Costs**.  Each Party to this Agreement shall bear its own legal and other costs incurred in connection with this matter, including the preparation and performance of this Agreement.
	**No Additional Releases**.  This Agreement is intended to be for the benefit of the Parties only, and by this instrument the Parties do not release any claims against or by any other person or entity.
	**Effect of Agreement**.  This Agreement constitutes the complete agreement between the Parties.  All material representations, understandings, and promises of the Parties are contained in this Agreement.  Any modifications to this Agreement shall be set forth in writing and signed by all Parties.
	**Execution of Agreement and Effective Date**.  The Agreement shall become effective (***i.e.***, final and binding) upon the date of signing of this Agreement and the CAP by the last signatory (Effective Date).
	**Tolling of Statute of Limitations**.  Pursuant to 42 U.S.C. § 1320a-7a(c)(1), a civil money penalty ("CMP") must be imposed within six years from the date of the occurrence of the violation.  To ensure that this six (6) year period does not expire during the term of this Agreement, DPC agrees that the time between the Effective Date of this Agreement and the date the Agreement may be terminated by reason of DPC's breach, plus one-year thereafter, will not be included in calculating the six (6) year statute of limitations applicable to the violations which are the subject of this Agreement.  DPC waives and will not plead any statute of limitations, laches, or similar defenses to any administrative action relating to the covered conduct identified in paragraph I.2 that is filed by HHS within the time period set forth above, except to the extent that such defenses would have been available had an administrative action been filed on the Effective Date of this Agreement.
	**Disclosure**.  HHS places no restriction on the publication of the Agreement.  In addition, HHS may be required to disclose material related to this Agreement to any person upon request consistent with the applicable provisions of the Freedom of Information Act, 5 U.S.C. § 552, and its implementing regulations, 45 C.F.R. Part 5.
	**Execution in Counterparts**.  This Agreement may be executed in counterparts, each of which constitutes an original, and all of which shall constitute one and the same agreement.
	**Authorizations**.  The individual(s) signing this Agreement on behalf of DPC represent and warrant that they are authorized by DPC to execute this Agreement.  The individual(s) signing this Agreement on behalf of HHS represent and warrant that they are signing this Agreement in their official capacities and that they are authorized to execute this Agreement.**For Danbury Psychiatry Consultants, LLC (DPC)**

/s/

Dr. Daniel Kelleher
Danbury Psychiatry Consultants, LLC

Date: 5/6/2022

**For Department of Health and Human Services**

/s/

Susan M. Pezzullo Rhodes
Regional Manager
Office for Civil Rights

Date: 5/9/2022

**Appendix A**

**CORRECTIVE ACTION PLAN BETWEEN THE DEPARTMENT OF HEALTH AND HUMAN SERVICES AND DANBURY PSYCHIATRY CONSULTANTS, LLC**

**I.  Preamble**

Danbury Psychiatry Consultants, LLC. ("DPC") hereby enters into this Corrective Action Plan ("CAP") with the United States Department of Health and Human Services, Office for Civil Rights ("HHS").  Contemporaneously with this CAP, DPC is entering into a Resolution Agreement ("Agreement") with HHS, and this CAP is incorporated by reference into the Resolution Agreement as Appendix A.  DPC enters into this CAP as part of consideration for the release set forth in paragraph II.8 of the Agreement.

**II.  Contact Persons and Submissions**

**Contact Persons**DPC has identified the following individual as its authorized representative and contact person regarding the implementation of this CAP and for receipt and submission of notifications and reports:

Dr. Daniel Kelleher
Danbury Psychiatry Consultants, LLC
72 North Street
Suite 300
Danbury, CT 06810
Email: Kelleher.dpc@gmail.com
Telephone: 203-917-3046

HHS has identified the following individual as its authorized representative and contact person with whom DPC is to report information regarding the implementation of this CAP:

Susan M. Pezzullo Rhodes
Office for Civil Rights, New England Region
U.S. Department of Health and Human Services
JFK Federal Building, Room 1875
Boston, MA  02203
Telephone:  617-565-1347
Facsimile:  617-565-3809

DPC and HHS agree to promptly notify each other of any changes in the contact persons or the other information provided above.

**Proof of Submissions**.  Unless otherwise specified, all notifications and reports required by this CAP may be made by any means, including certified mail, overnight mail, or hand delivery, provided that there is proof that such notification was received. For purposes of this requirement, internal facsimile confirmation sheets do not constitute proof of receipt.**III.  Effective Date and Term of CAP**

The Effective Date for this CAP shall be calculated in accordance with paragraph II.14 of the Agreement ("Effective Date").  The period for compliance ("Compliance Term") with the obligations assumed by DPC under this CAP shall begin on the Effective Date of this CAP and end two (2) years from the Effective Date unless HHS has notified DPC under section VIII hereof of its determination that DPC breached this CAP.  In the event of such a notification by HHS under section VIII hereof, the Compliance Term shall not end until HHS notifies DPC that it has determined that the breach has been cured.  After the Compliance Term ends, DPC shall still be obligated to submit the final Annual Report as required by section VI and comply with the document retention requirement in section VII.

**IV.  Time**

In computing any period of time prescribed or allowed by this CAP, all days referred to shall be calendar days.  The day of the act, event, or default from which the designated period of time begins to run shall not be included. The last day of the period so computed shall be included, unless it is a Saturday, a Sunday, or a legal holiday, in which event the period runs until the end of the next day which is not one of the aforementioned days.

**V.  Corrective Action Obligations**

DPC agrees to the following:

**Policies and Procedures**

	DPC shall develop, maintain, and revise, as necessary, its written policies and procedures to comply with the Federal standards that govern the privacy of individually identifiable health information (45 C.F.R. Part 160 and Subparts A and E of Part 164, the "Privacy Rule").  DPC's policies and procedures shall include, but not be limited to, the minimum content set forth in section V.C.
		DPC shall provide such policies and procedures, consistent with paragraph 1 above, to HHS within sixty (60) days of the Effective Date for review and approval.  Upon receiving any recommended changes to such policies and procedures from HHS, DPC shall have thirty (30) days to revise such policies and procedures accordingly and provide the revised policies and procedures to HHS for review and approval.
		DPC shall implement such policies and procedures within thirty (30) days of receipt of HHS' approval.
	**Distribution and Updating of Policies and Procedures**
	DPC shall distribute the policies and procedures identified in section V.A. to all members of the workforce within thirty (30) days of HHS approval of such policies and to new members of the workforce within thirty (30) days of their beginning of service.
		DPC shall require, at the time of distribution of such policies and procedures, a signed written or electronic initial compliance certification from all members of the workforce, stating that the workforce members have read, understand, and shall abide by such policies and procedures.
		DPC shall assess, update, and revise, as necessary, the policies and procedures at least annually. DPC shall provide such revised policies and procedures to HHS for review and approval. Within thirty (30) of the effective date of any approved substantive revisions, DPC shall distribute such revised policies and procedures to all members of its workforce, and shall require new compliance certifications.
	**Minimum Content of the Policies and Procedures**
	The Policies and Procedures shall include, but not be limited to:
	Right of access to protected health information under 45 C.F.R. §164.524 and all its subparts, including procedures that permit an individual to request access to inspect or to obtain a copy of protected health information about the individual that is maintained in a designated record set and to ensure timely and accurate responses to such requests; and
		Protocols for training all DPC's workforce members that are involved in receiving or fulfilling access requests as necessary and appropriate to ensure compliance with the policies and procedures provided for in section V.A. above.
	**Reportable Events.**
	During the Compliance Term, DPC shall, upon receiving information that a workforce member may have failed to comply with the policies and procedures described in Section V.A.1., promptly investigate this matter. If DPC determines, after review and investigation, that a member of its workforce has failed to comply with these policies and procedures, DPC shall notify HHS in writing within thirty (30) days and in the Annual Report, as set forth in Section VI.B.4. Such violations shall be known as Reportable Events. The report shall include the following information:
	A complete description of the event, including the relevant facts, the persons involved, and the provision(s) of the policies and procedures implicated; and
		A description of the actions taken and any further steps DPC plans to take to address the matter to mitigate any harm, and to prevent it from recurring, including application of appropriate sanctions against workforce members who failed to comply with its Privacy Rule Policies and Procedures.
	**Training**
	DPC shall provide HHS with training materials per section V.C. above for all members of the workforce within sixty (60) days of the approval of its policies and procedures per section V.A.
		Upon receiving notice from HHS specifying any required changes, DPC shall make the required changes and provide revised training materials to HHS within thirty (30) days.
		Upon receiving approval from HHS of any revised training materials, DPC shall provide training on any revised training materials for each workforce member within sixty (60) days of HHS approval and annually thereafter. DPC shall also provide such training to each new member of the workforce within thirty (30) days of their beginning of service.
		Each workforce member who is required to attend the training shall certify, in electronic or written form, that he or she has received the training.  The training certification shall specify the date training was received.  All course materials shall be retained in compliance with section VII.
		DPC shall review the training at least annually, and, where appropriate, update the training to reflect changes in Federal law or HHS guidance, any issues discovered during audits or reviews, and any other relevant developments.**VI.  Implementation Report and Annual Reports**

**Implementation Report**.
	Within 120 days after the receipt of HHS' approval of the policies and procedures required by section V.A.1, DPC shall submit a written report to HHS summarizing the status of its implementation of the requirements of this CAP.  This report, known as the "Implementation Report," shall include:
	An attestation signed by an owner or officer of DPC attesting that the Policies and Procedures are being implemented, have been distributed to all appropriate members of the workforce, and that DPC has obtained all of the compliance certifications required by sections V.B.2. and V.B.3.;
		A copy of all training materials used for the training required by this CAP, a description of the training, including a summary of the topics covered, the length of the session(s) and a schedule of when the training session(s) were held;
		An attestation signed by an owner or officer of DPC attesting that all members of the workforce have completed the initial training required by this CAP and have executed the training certifications required by section V.E.4.;
		An attestation signed by an owner or officer of DPC stating that he or she has reviewed the Implementation Report, has made a reasonable inquiry regarding its content and believes that, upon such inquiry, the information is accurate and truthful.
	**Annual Reports**.
	The one (1) year period after the Effective Date and each subsequent one (1) year period during the course of the Compliance Term shall be known as a "Reporting Period." Within sixty (60) days after the close of the Reporting Period, DPC shall submit a report or reports to HHS regarding DPC' compliance with this CAP for the Reporting Period ("Annual Report"). The Annual Report shall include:
	A schedule, topic outline, and copies of the training materials for the training programs attended in accordance with this CAP during the Reporting Period that is the subject of the report;
		An attestation signed by an owner or officer of DPC attesting that it is obtaining and maintaining written or electronic training certifications from all persons that require training that they received training pursuant to the requirements set forth in this CAP;
		An attestation signed by an officer or director of DPC attesting that any revision(s) to the Policies and Procedures required by section V were finalized and adopted within thirty (30) days of HHS' approval of the revision(s), which shall include a statement affirming that DPC distributed the revised Policies and Procedures to all appropriate members of DPC' workforce within sixty (60) days of HHS' approval of the revision(s); and
		A summary of Reportable Events (defined in section V.D.) identified during the Reporting Period and the status of any corrective and preventative action relating to all such Reportable Events, or an attestation signed by an officer or director of DPC stating that no Reportable Events occurred during the Compliance Term;
		An attestation signed by an owner or officer of DPC attesting that he or she has reviewed the Annual Report, has made a reasonable inquiry regarding its content and believes that, upon such inquiry, the information is accurate and truthful.**VII.  Document Retention**

DPC shall maintain for inspection and copying, and shall provide to OCR, upon request, all documents and records relating to compliance with this CAP for six (6) years from the Effective Date.

**VIII.  Breach Provisions**

DPC is expected to fully and timely comply with all provisions contained in this CAP.

**Timely Written Requests for Extensions**.  DPC may, in advance of any due date set forth in this CAP, submit a timely written request for an extension of time to perform any act required by this CAP.  A "timely written request" is defined as a request in writing received by HHS at least five (5) days prior to the date such an act is required or due to be performed.
	**Notice of Breach of this CAP and Intent to Impose Civil Monetary Penalty**.  The parties agree that a breach of this CAP by DPC constitutes a breach of the Agreement.  Upon a determination by HHS that DPC has breached this CAP, HHS may notify DPC of: (1) DPC's breach; and (2) HHS' intent to impose a civil money penalty ("CMP") pursuant to 45 C.F.R. Part 160, or other remedies for the Covered Conduct set forth in paragraph I.2 of the Agreement and any other conduct that constitutes a violation of the HIPAA Privacy, Security, or Breach Notification Rules ("Notice of Breach and Intent to Impose CMP").
	**DPC's Response**.  DPC shall have thirty (30) days from the date of receipt of the Notice of Breach and Intent to Impose CMP to demonstrate to HHS' satisfaction that:
	DPC is in compliance with the obligations of the CAP that HHS cited as the basis for the breach;
		The alleged breach has been cured; or
		The alleged breach cannot be cured within the thirty (30) day period, but that: (a) DPC has begun to take action to cure the breach; (b) DPC is pursuing such action with due diligence; and (c) DPC has provided to HHS a reasonable timetable for curing the breach.
	**Imposition of CMP**.  If at the conclusion of the thirty (30) day period, DPC fails to meet the requirements of section VIII.C. of this CAP to HHS' satisfaction, HHS may proceed with the imposition of a CMP against DPC pursuant to 45 C.F.R. Part 160 for any violations of the Covered Conduct set forth in paragraph I.2 of the Agreement and for any other act or failure to act that constitutes a violation of the HIPAA Rules.  HHS shall notify DPC in writing of its determination to proceed with the imposition of a CMP pursuant to 45 C.F.R. §§ 160.312(a)(3)(i) and (ii).**For Danbury Psychiatry Consultants, LLC (DPC)**

/s/

Dr. Daniel Kelleher
Danbury Psychiatry Consultants, LLC

Date: 5/6/2022

**For Department of Health and Human Services**

/s/

Susan M. Pezzullo Rhodes
Regional Manager, New England Region
Office for Civil Rights

Date: 5/9/2022

                    
  


Content created by Office for Civil Rights (OCR) Content last reviewed July 15, 2022Back to top
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