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                              Lawrence Bell, Jr., D.D.S. Resolution Agreement and Corrective Action Plan


    

    

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Lawrence Bell, Jr., D.D.S. 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).
		Lawrence Bell, Jr., D.D.S., P.A., a dental practice, is a covered entity, as defined at 45 C.F.R. § 160.103, is required to comply with the HIPAA Rules.  Lawrence Bell, Jr., D.D.S., P.A. is located in Baltimore, MD.
		HHS and Lawrence Bell, Jr., D.D.S., P.A. shall together be referred to herein as the "Parties."
	**Factual Background and Covered Conduct**.On October 15, 2019, OCR received a complaint alleging that Lawrence Bell, Jr., D.D.S., P.A. is not in compliance with the Privacy Rule.  The complaint alleged that Lawrence Bell, Jr., D.D.S., P.A. failed to provide its client, the Affected Party, with access to his protected health information.  The Affected Party requested access in writing on July 15, 2019.OCR's investigation indicated the following conduct occurred ("Covered Conduct"):

Lawrence Bell, Jr., D.D.S., P.A. failed to provide timely access to protected health information about an individual in a designated records set. *See* 45 C.F.R. § 164.524(b).

**No Admission**.This Agreement is not an admission of liability by Lawrence Bell, Jr., D.D.S., P.A..
	**No Concession**.This Agreement is not a concession by HHS that Lawrence Bell, Jr., D.D.S., P.A. is not in violation of the HIPAA Rules and not liable for a civil money penalty ("CMP").
	**Intention of Parties to Effect Resolution.** This Agreement is intended to resolve OCR Transaction Number 20-360870 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 Lawrence Bell, Jr., D.D.S., P.A. has agreed to pay HHS, the amount of $5,000 ("Resolution Amount").  Lawrence Bell, Jr., D.D.S., P.A. agrees to pay the Resolution Amount on the Effective Date of this Agreement as defined in paragraph II.14 by automated clearing house transaction pursuant to written instructions to be provided by HHS.
	**Corrective Action Plan**.  Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A. breaches the CAP, and fails to cure the breach as set forth in the CAP, then Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A.'s performance of its obligations under this Agreement, HHS releases Lawrence Bell, Jr., D.D.S., P.A. from any actions it may have against Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A. 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 Party**.  Lawrence Bell, Jr., D.D.S., P.A. 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.  Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A. 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 CMP must be imposed within six (6) years from the date of the occurrence of the violation. To ensure that this six-year period does not expire during the term of this Agreement, Lawrence Bell, Jr., D.D.S., P.A. agrees that the time between the Effective Date of this Agreement (as set forth in Paragraph 14) and the date the Agreement may be terminated by reason of Lawrence Bell, Jr., D.D.S., P.A.'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.  Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A. represent and warrant that they are authorized by Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A.**

/s/

Lawrence Bell, III
Owner

Date: 4/1/2022

**For the United States Department of Health and Human Services**

/s/

Jamie Rahn Ballay
Regional Manager
Office for Civil Rights, Mid-Atlantic Region

Date: 4/1/2022**Appendix A**

**CORRECTIVE ACTION PLAN** **BETWEEN THE** **DEPARTMENT OF HEALTH AND HUMAN SERVICES** **AND********LAWRENCE BELL, JR., D.D.S., P.A.**

**I.  Preamble**

Lawrence Bell, Jr., D.D.S., P.A. 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, Lawrence Bell, Jr., D.D.S., P.A. is entering into a Resolution Agreement ("Agreement") with HHS, and this CAP is incorporated by reference into the Agreement as Appendix A.  Lawrence Bell, Jr., D.D.S., P.A. enters into this CAP as part of the consideration for the release set forth in paragraph II.8 of the Agreement.  Capitalized terms without definition in this CAP shall have the same meaning assigned to them under the Agreement.

**II.  Contact Persons and Submissions**

**Contact Persons**.Lawrence Bell, Jr., D.D.S., P.A. 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:

Lawrence Bell, III
Bell Dental Center
3326 Auchentoroly Ter.
Baltimore, MD  21217
Phone: 410-669-0700
Fax: 410-669-1284

HHS has identified the following individual as its authorized representative and contact person with whom Lawrence Bell, Jr., D.D.S., P.A. is to report information regarding the implementation of this CAP:

Jamie Rahn Ballay
Regional Manager
Office for Civil Rights, Mid-Atlantic Region
U.S. Department of Health and Human Services
801 Market St., Suite 9300
Philadelphia, PA 19107
Phone: 215-861-4432
Fax: 215-861-4431jamie.rahn@hhs.gov

Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A. under section VIII hereof of its determination that Lawrence Bell, Jr., D.D.S., P.A. has 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 Lawrence Bell, Jr., D.D.S., P.A. that it has determined that the breach has been cured.  After the Compliance Term ends, Lawrence Bell, Jr., D.D.S., P.A. shall still be obligated to: (a) submit the final Annual Report as required by section VI; and (b) 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**

Lawrence Bell, Jr., D.D.S., P.A. agrees to the following:

**Provide Affected Party with Access to his Protected Health Information**

	Within fifteen (15) days following the Effective Date of the Agreement, Lawrence Bell, Jr., D.D.S., P.A. shall provide the Affected Party with access to his requested records, in whole or in part, and/or provide a denial, in whole or in part, consistent with 45 C.F.R. § 164.524.
	**Review and Revise Policies and Procedures for Individual Access to Protected Health Information**
	Within thirty (30) calendar days of the Effective Date, Lawrence Bell, Jr., D.D.S., P.A. shall review, and to the extent necessary, revise its 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").   Lawrence Bell, Jr., D.D.S., P.A.'s policies and procedures shall address, but not be limited to, the Covered Conduct specified in paragraph I.2 of the agreement.
		Lawrence Bell, Jr., D.D.S., P.A. 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, Lawrence Bell, Jr., D.D.S., P.A. 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.
		Lawrence Bell, Jr., D.D.S., P.A. shall implement such policies and procedures within thirty (30) days of receipt of HHS' approval.
	**Distribution and Updating of Policies and Procedures**
	Lawrence Bell, Jr., D.D.S., P.A. shall distribute the policies and procedures identified in section V.B to all members of the workforce and relevant business associates within thirty (30) days of HHS approval of such policies, and to new members of the workforce within thirty (30) days of their beginning services.
		Lawrence Bell, Jr., D.D.S., P.A. 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 and relevant business associates stating that the workforce member have read, understand, and shall abide by such policies and procedures.
		Lawrence Bell, Jr., D.D.S., P.A. shall assess, update, and revise, as necessary, the policies and procedures at least annually or as needed.  Lawrence Bell, Jr., D.D.S., P.A. shall distribute such revised policies and procedures to all members of its workforce and relevant business associates and shall require new compliance certifications.
	**Minimum Content of Policies and Procedures**
	Review and update as necessary Lawrence Bell, Jr., D.D.S., P.A.'s Right of Access to protected health information to ensure comprehensive responses to requests for records and a denial process consistent with the Privacy Rule.
		Protocols for training all Lawrence Bell, Jr., D.D.S., P.A.'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.B above.
		Application of appropriate sanctions against Lawrence Bell, Jr., D.D.S., P.A. workforce members who fail to comply with policies and procedures provided for in subparagraph 1 above.
		Review and update as necessary Lawrence Bell, Jr., D.D.S., P.A.'s policy for cooperation with investigations and compliance reviews conducted by the Secretary to ensure comprehensive compliance investigations and review.
		Protocols for training all Lawrence Bell, Jr., D.D.S., P.A.'s workforce members that are involved with cooperating with investigations and compliance reviews conducted by the Secretary to ensure compliance with the policies and procedures provided for in section V.B above.
	**Access Request Status Requirements**
	Within ninety (90) calendar days of receipt of HHS' approval of the policies and procedures required by section V.B and every ninety (90) calendar days thereafter while under the Term of this CAP, Lawrence Bell, Jr., D.D.S., P.A. shall submit to HHS a list of requests for access to protected health information received by Lawrence Bell, Jr., D.D.S., P.A., including the date request received, date request completed, format requested, format provided, number of pages (if provided in paper format, and cost, excluding postage).
		If Lawrence Bell, Jr., D.D.S., P.A. denied any request for access, in whole or in part, Lawrence Bell, Jr., D.D.S., P.A. shall submit to HHS all documentation consistent with 45 C.F.R. § 164.524(d).
	**Training**
	Lawrence Bell, Jr., D.D.S., P.A. shall provide HHS with training materials per section V.D. above for all members of the workforce within sixty (60) days of the approval of its policies and procedures per section V.B.
		Upon receiving notice from HHS specifying any required changes, Lawrence Bell, Jr., D.D.S., P.A. shall make the required changes and provide revised training materials to HHS within thirty (30) days.
		Upon receiving approval from HHS, Lawrence Bell, Jr., D.D.S., P.A. shall provide training for each workforce member within ninety (90) days of HHS approval and at least every twelve (12) months thereafter.  Lawrence Bell, Jr., D.D.S., P.A. shall also provide such training to each new member of the workforce or relevant new business associate within thirty (30) days of their beginning of service.
		Each workforce member who is required to attend 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.
		Lawrence Bell, Jr., D.D.S., P.A. 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.  Reportable Events, Implementation Report, and Annual Reports**

**Reportable Events**

	During the Compliance Term, Lawrence Bell, Jr., D.D.S., P.A. shall, upon receiving information that a workforce member may have failed to comply with its access policies and procedures, promptly investigate this matter.  If Lawrence Bell, Jr., D.D.S., P.A. determines, after review and investigation, that a member of its workforce has failed to comply with these policies and procedures, Lawrence Bell, Jr., D.D.S., P.A. shall notify HHS in writing within thirty (30) days.  Such violations shall be known as Reportable Events. The report to HHS 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 Lawrence Bell, Jr., D.D.S., P.A. 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.
	**Implementation Report**
	Within one hundred twenty (120) calendar days after the receipt of HHS's approval of the policies and procedures required by section V.B, Lawrence Bell, Jr., D.D.S., P.A. 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 Lawrence Bell, Jr., D.D.S., P.A. attesting that the policies and procedures approved by HHS in section V.B. are being implemented;
			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 Lawrence Bell, Jr., D.D.S., P.A. attesting that all members of the workforce have completed the initial training required by section V.F;
			An attestation signed by an owner or officer of Lawrence Bell, Jr., D.D.S., P.A. 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) calendar days after the close of each corresponding Reporting Period, Lawrence Bell, Jr., D.D.S., P.A. shall submit a report to HHS regarding Lawrence Bell, Jr., D.D.S., P.A.'s compliance with this CAP for each corresponding Reporting Period ("Annual Report").  The Annual Report shall include:
		An attestation signed by an owner or officer of Lawrence Bell, Jr., D.D.S., P.A. attesting that all members of the workforce have completed the training required by section V.F. during the Reporting Period;
			An attestation signed by an officer or owner of Lawrence Bell, Jr., D.D.S., P.A. attesting that any revision(s) to the policies and procedures required by section V.B were finalized and adopted within thirty (30) calendar days of HHS's approval of the revision(s), which shall include a statement affirming that Lawrence Bell, Jr., D.D.S., P.A. distributed the revised policies and procedures to all appropriate members of Lawrence Bell, Jr., D.D.S., P.A.'s workforce within sixty (60) calendar days of HHS's approval of the revision(s);
			A summary of Reportable Events (defined in section VI.A), if any, the status of any corrective and preventative action(s) relating to all such Reportable Events, or an attestation signed by an officer or director of Lawrence Bell, Jr., D.D.S., P.A. stating that no Reportable Events occurred during the Compliance Term.
			An attestation signed by an owner or officer of Lawrence Bell, Jr., D.D.S., P.A. 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**

Lawrence Bell, Jr., D.D.S., P.A. shall maintain for inspection and copying, and shall provide to HHS, upon request, all documents and records relating to compliance with this CAP for six (6) years from the Effective Date.

**VIII.  Requests for Extensions and Breach Provisions**

Lawrence Bell, Jr., D.D.S., P.A. is expected to fully and timely comply with all provisions contained in this CAP.

**Timely Written Requests for Extensions**. Lawrence Bell, Jr., D.D.S., P.A. 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) calendar 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 Lawrence Bell, Jr., D.D.S., P.A. constitutes a breach of the Agreement. Upon a determination by HHS that Lawrence Bell, Jr., D.D.S., P.A. has breached this CAP, HHS may notify Lawrence Bell, Jr., D.D.S., P.A. of: (1) Lawrence Bell, Jr., D.D.S., P.A.'s breach; and (2) HHS' intent to impose a 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 for any other conduct that constitutes a violation of the HIPAA Privacy, Security, and Breach Notification Rules ("Notice of Breach and Intent to Impose CMP").
	**Lawrence Bell, Jr., D.D.S., P.A. Response***.*Lawrence Bell, Jr., D.D.S., P.A. shall have thirty (30) calendar days from the date of receipt of the Notice of Breach and Intent to Impose CMP to demonstrate to HHS' satisfaction that:
	Lawrence Bell, Jr., D.D.S., P.A. 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) Lawrence Bell, Jr., D.D.S., P.A. has begun to take action to cure the breach; (b) Lawrence Bell, Jr., D.D.S., P.A. is pursuing such action with due diligence; and (c) Lawrence Bell, Jr., D.D.S., P.A. has provided to HHS a reasonable timetable for curing the breach.
	**Imposition of CMP**. If at the conclusion of the thirty (30) day period, Lawrence Bell, Jr., D.D.S., P.A. fails to meet the requirements of section VIII.C of this CAP to HHS's satisfaction, HHS may proceed with the imposition of the CMP against Lawrence Bell, Jr., D.D.S., P.A. pursuant to 45 C.F.R. Part 160 for any violations of the Covered Conduct set forth in paragraph 2 of the Agreement and for any other act or failure to act that constitutes a violation of the HIPAA Rules. HHS shall notify Lawrence Bell, Jr., D.D.S., P.A. in writing of its determination to proceed with the imposition of the CMP.**For Lawrence Bell, Jr., D.D.S., P.A.:**

/s/

Lawrence Bell, III
Owner

Date: 4/1/2022

**For the United States Department of Health and Human Services**

/s/

Jamie Rahn Ballay
Regional Manager
Office for Civil Rights, Mid-Atlantic Region

Date: 4/1/2022

                    
  


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