Resolution Agreement, Neurology Practice
HHS Office for Civil Rights Settles HIPAA Ransomware Cybersecurity Investigation with Neurology Practice
Cite as In re Neurology Practice, HHS OCR Resolution Agreement (2025-04-25)
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RESOLUTION AGREEMENT
I. Recitals
1. Parties. The Parties to this Resolution Agreement (“Agreement”) are:
A. The United States Department of Health and Human Services, Office for Civil Rights (“HHS”)
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).
B. Comprehensive Neurology, PC (“Comprehensive”) is a covered entity, as defined at 45 C.F.R. §
160.103, and therefore is required to comply with the HIPAA Rules. Comprehensive consists of a single
physician neurologist, Dr. Gene Zitser. Comprehensive is in Hollis, New York. Comprehensive is an S
corporation with five full-time staff members not including Dr. Zitser. Comprehensive specializes in
general neurology, stroke treatment and prevention, epilepsy, neurobehavioral disorders, vertigo, sleep
disorders, neurophysiology (EEG/EMG/Nerve conduction studies), fibromyalgia, back pain/headache,
dementia/ Alzheimer's, and movement disorders (Parkinson's, tremors).
C. HHS and Comprehensive shall together be referred to herein as the “Parties.”
2. Factual Background and Covered Conduct.
On December 17, 2020, the U.S. Department of Health and Human Services (HHS), Office for Civil
Rights (OCR) received a breach notification report from Comprehensive. Comprehensive reported
that on December 14, 2020, Comprehensive became aware of an issue with its systems when an
employee discovered that they could not access medical records. Comprehensive’s internal
investigation determined that it had been subjected to ransomware and that 6,800 individuals may
have been affected by the breach incident.
HHS’ investigation indicated that the following conduct occurred (“Covered Conduct”):
(i) Comprehensive failed to conduct an accurate and thorough risk analysis of the potential risks and
vulnerabilities to ePHI held by Comprehensive. See 45 C.F.R. §164.308(a)(1)(ii)(A).
3. No Admission. This Agreement is not an admission of liability by Comprehensive.
4. No Concession. This Agreement is not a concession by HHS that Comprehensive is not in
violation of the HIPAA Rules and is not liable for civil money penalties.
5. Intention of Parties to Effect Resolution. This Agreement is intended to resolve OCR Transaction
Number 21-407151 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 formal proceedings, the Parties agree to resolve this matter according to the
Terms and Conditions below.
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II. Terms and Conditions
6. Payment. Comprehensive has agreed to pay HHS the amount of $25,000 (“Resolution Amount”).
Comprehensive agrees to pay the Resolution Amount in one lump sum within three (3) days of the
Effective Date of this Agreement as defined in paragraph II.14 pursuant to written instructions to be
provided by HHS.
7. Corrective Action Plan. Comprehensive 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 Comprehensive breaches the CAP and fails to cure the breach as set forth in the CAP,
then Comprehensive 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.
8. Release by HHS. In consideration of and conditioned upon Comprehensive’s performance of its
obligations under this Agreement, HHS releases Comprehensive from any actions it may have against
Comprehensive 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 Comprehensive 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.
9. Agreement by Released Parties. Comprehensive 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. Comprehensive 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.
10. Binding on Successors. This Agreement is binding on Comprehensive and its successors, heirs,
transferees, and assigns.
11. 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.
12. 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.
13. 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.
14. 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).
15. 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-year period does not expire during the term of this Agreement, Comprehensive agrees
that the time between the Effective Date of this Agreement and the date the Agreement may be
terminated by reason of Comprehensive’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
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this Agreement. Comprehensive 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.
16. Disclosure. HHS places no restriction on the publication of the Agreement.
17. 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.
18. Authorizations. The individual(s) signing this Agreement on behalf of Comprehensive represent
and warrant that they are authorized by Comprehensive 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 Covered Entity
/s
Dr. Gene Zitser
Comprehensive Neurology, PC
2/7/2025
Date
For U.S. Department of Health and Human Services
/s
Linda C. Colón
Regional Manager
Eastern and Caribbean Region
Office for Civil Rights
2/10/2025
Date
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APPENDIX A
CORRECTIVE ACTION PLAN
BETWEEN THE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AND
COMPREHENSIVE NEUROLOGY, PC
I.
Preamble
Comprehensive Neurology, PC. (Hereinafter known as “Comprehensive”) 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, Comprehensive is entering into a
Resolution Agreement (“Agreement”) with HHS, and this CAP is incorporated by reference into the
Resolution Agreement as Appendix A. Comprehensive enters into this CAP as part of consideration
for the release outlined in paragraph II.8 of the Agreement.
II. Contact Persons and Submissions
A. Contact Persons
Comprehensive 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. Gene Zitser
19503 Hillside Ave
Hollis, New York 11423
REDACTED
REDACTED
HHS has identified the following individual as its authorized representative and contact person with
whom Comprehensive is to report information regarding the implementation of this CAP:
Linda C. Colón, Regional Manager
Eastern and Caribbean Region
Office for Civil Rights
U.S. Department of Health and Human Services
26 Federal Plaza, Suite 19-501
New York, NY 10278
REDACTED
REDACTED
Comprehensive and HHS agree to promptly notify each other of any changes in the contact persons or
the other information provided above.
B. 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.
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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 Comprehensive 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 Comprehensive under Section VIII
hereof of its determination that Comprehensive 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
Comprehensive that it has determined that the breach has been cured. After the Compliance Term
ends, Comprehensive shall still be obligated to submit the final Annual Report as required by Section
V.F and comply with the document retention requirement in Section VI. Nothing in this CAP is
intended to eliminate or modify Comprehensive’s obligation to comply with the document retention
requirements in 45 C.F.R. § 164.316(b) and § 164.530(j).
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
Comprehensive agrees to take the corrective action steps specified below.
A. Conduct Risk Analysis
1. Comprehensive shall conduct an accurate and thorough assessment of the potential security
risks and vulnerabilities to the confidentiality, integrity, and availability of the Comprehensive’s
electronic protected health information (“ePHI”) (“Risk Analysis”). The Risk Analysis shall
incorporate all Comprehensive’s locations and facilities and must include an evaluation of the
risks to the security of ePHI in electronic equipment, data systems, and programs and
applications controlled, administered, owned, or shared by Comprehensive, that contain, store,
transmit, or receive ePHI. The Risk Analysis shall also include an assessment of
Comprehensive’s environmental controls.1 Prior to conducting the Risk Analysis, Comprehensive shall
develop a complete inventory of all of its facilities, electronic equipment, data systems, programs, and
applications that contain or store ePHI, which will then be incorporated into the Risk Analysis.
2. Within sixty (60) days of the Effective Date, Comprehensive shall submit to HHS the scope
and methodology by which it proposes to conduct the Risk Analysis described in paragraph
V.A.1. HHS shall notify Comprehensive whether the proposed scope and methodology is or is not
consistent with 45 C.F.R. § 164.308 (a)(1)(ii)(A).
3. Comprehensive shall provide the Risk Analysis, consistent with paragraph V.A.l., to HHS
within one hundred twenty (120) days of HHS’ approval of Comprehensive’s methodology
described in paragraph V.A.2 for HHS’ review. Within ninety (90) days of its receipt of
Comprehensive’s Risk Analysis, HHS will inform Comprehensive’s Contact in writing as to
whether HHS approves of the Risk Analysis or, if necessary to ensure compliance with 45
1 Environmental controls may include fire suppression systems, water prevention systems (e.g., drainage, raised floors),
power supply, climate control, etc.
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C.F.R. § 164.308(a)(1)(ii)(A), requires revisions to the Risk Analysis. If HHS requires revisions to the
Risk Analysis, HHS shall provide Comprehensive’s Contact with a detailed, written explanation of such
required revisions and with comments and recommendations in order for Comprehensive to be able to
prepare a revised Risk Analysis. Upon receiving notice of required revisions to the Risk Analysis from
HHS and a description of any required changes to the Risk Analysis, Comprehensive shall have thirty
(30) days in which to revise its Risk Analysis accordingly and submit the revised Risk Analysis to HHS
for review and approval. This submission and review process shall continue until HHS approves the
Risk Analysis.
B. Develop and Implement a Risk Management Plan
1. Comprehensive shall develop a written risk management plan or plans sufficient to address and
mitigate any and all security risks and vulnerabilities identified in the Risk Analysis described in
Section V.A above (“Risk Management Plan”). The Risk Management Plan shall include a
process and timeline for Comprehensive’s implementation, evaluation, and revision of their risk
remediation activities.
2. Within sixty (60) days of HHS’ final approval of the Risk Analysis described in Section V.A.1
above, Comprehensive shall submit its Risk Management Plan to HHS for HHS’ review.
Within sixty (60) days of its receipt of the Risk Management Plan, HHS will inform
Comprehensive’s Contact in writing as to whether HHS approves of the Risk Management
Plan or, if necessary to ensure compliance with 45 C.F.R. § 164.308(a)(1)(ii)(B), requires
revisions to the Risk Management Plan. If HHS requires revisions to the Risk Management
Plan, HHS shall provide Comprehensive’s Contact with detailed comments and
recommendations in order for Comprehensive to be able to prepare a revised Risk
Management Plan. Upon receiving notice of required revisions to the Risk Management Plan
from HHS and a description of any required changes to the Risk Management Plan,
Comprehensive shall have thirty (30) days in which to revise its Risk Management Plan
accordingly and submit the revised Risk Management Plan to HHS for review and approval.
This submission and review process shall continue until HHS approves the Risk Management
Plan.
3. Within thirty (30) days of HHS’ approval of the Risk Management Plan, Comprehensive shall
begin implementation of the Risk Management Plan and distribute the plan to workforce
members, as appropriate, involved with the implementation of the plan.
C. Policies and Procedures
1. Comprehensive shall review and, to the extent necessary, revise, its current Privacy, Security,
and Breach Notification Rule Policies and Procedures (“Policies and Procedures”) based on the
findings of the risk analysis and the implementation of the risk management plan, as required
by Sections V.A. and V.B. above. Comprehensive Policies and Procedures must comply with
the HIPAA’s Privacy and Security Rules. Comprehensive policies and procedures shall include,
but not be limited to, the minimum content set forth in Section V.E. If no revisions are
needed, Comprehensive will report that to HHS.
2. Comprehensive shall provide the Policies and Procedures, consistent with paragraph 1 above, to
HHS within 60 days of the implementation of the Risk Management Plan for review and
approval. Upon receiving any recommended changes to the Policies and Procedures from
HHS, Comprehensive shall have 30 days to revise them accordingly and provide the revised
Policies and Procedures to HHS for review and approval.
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3. Comprehensive shall implement such policies and procedures within 30 days of receipt of
HHS’ final approval.
D. Distribution and Updating of Policies and Procedures
1. Comprehensive shall distribute the Policies and Procedures identified in Section V.C. 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.
2. Comprehensive shall require, at the time of distribution of the 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.
3. Comprehensive shall assess, update, and revise, if necessary, the Policies and Procedures at
least annually (and more frequently if appropriate). Comprehensive shall provide such revised
policies and procedures to HHS for review and approval. Upon receiving any recommended
changes to the Policies and Procedures from HHS, Comprehensive shall have thirty days to
revise such policies and procedures accordingly and provide the revised Policies and
Procedures to HHS for review and approval. Within thirty days of the effective date of any
approved substantive revisions, Comprehensive shall distribute the revised Policies and
Procedures to all members of its workforce, and new members as required by Section V.D.1,
and shall require new compliance certifications. If no revisions are needed, Comprehensive
will report that to HHS.
4. Comprehensive shall not provide access to ePHI to any member of its workforce if that
workforce member has not signed or provided the written or electronic certification required
by paragraphs 2 and 3 of this Section.
E. Minimum Content of the Policies and Procedures
The Policies and Procedures shall include, but not be limited to, measures to address the following
Privacy, Security, and Breach Notification Rule provisions:
1. Risk Analysis- 45 C.F.R. §164.308(a)(1)(ii)(A), including a process(es) to conduct an accurate
and thorough assessment of the potential risks and vulnerabilities to the confidentiality,
integrity, and availability of ePHI held by Comprehensive.
2. Risk Management- 45 C.F.R. §164.308(a)(1)(ii)(B), including a process(es) to implement
security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate
level.
3. Security Awareness and Training- 45 C.F.R. §164.308(a)(5), including a process(es) for HIPAA
Privacy and Security awareness and training program for all members of Comprehensive’s
existing workforce.
4. Security Incident Procedures- 45 C.F.R. §164.308(a)(6)(i), including a process(es) to address
security incidents.
5. Data Backup Plan---45 C.F.R. § 164.308(a)(7), including establishing and implementing
procedures to create and maintain retrievable exact copies of electronic protected health
information.
6. Breach Notification Rule---including as relates to breach risk assessments at 45 C.F.R.
§164.402 and notification by a business associate at 45 C.F.R. § 164.410.
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7. Information System Activity Review – 45 C.F.R. §308(a)(1)(ii)(D), including a process(es) for
the regular review of all records of information system activity collected by Comprehensive
and processes for evaluating when the collection of new or different records needs to be
included in the review; including parameters for reviewing systems’ activity, the frequency of
reviews, and procedures for documenting and reporting results of such reviews.
F. Reportable Events
During the Compliance Term, Comprehensive shall, upon receiving information that a workforce
member may have failed to comply with its Privacy, Security, or Breach Notification Rule Policies and
Procedures, or that a business associate may have failed to comply with the provisions of the business
associate agreement, as applicable, promptly investigate this matter. If Comprehensive determines,
after review and investigation, that a member of its workforce, or a business associate that has agreed
to comply with policies and procedures under Section V.D.3, has failed to comply with these policies
and procedures, Comprehensive 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
b. A description of the actions taken and any further steps Comprehensive plans to take to
address the matter to mitigate any harm, and to prevent it from recurring, including the
application of appropriate sanctions against workforce members who failed to comply with its
Privacy, Security, or Breach Notification Rule Policies and Procedures.
G. Training
1. Comprehensive shall provide HHS with training materials addressing the requirements of the
Privacy, Security, and Breach Notification Rules, intended to be used for all workforce
members within sixty (60) days of the implementation of the Policies and Procedure required
by Section V.C. above, if any.
2. Upon receiving notice from HHS specifying any required changes, Comprehensive shall make
the required changes and provide revised training materials to HHS within thirty (30) days, if
needed.
3. Upon receiving approval from HHS, Comprehensive shall provide training using the approved
training materials for all workforce members within sixty (60) days of HHS’ approval and at
least every twelve (12) months thereafter. Comprehensive shall also provide such training to
each workforce member within thirty (30) days of the commencement of such workforce
member’s service.
4. Each workforce member shall certify, in writing or electronic form, that she or he has received
and understands the required training. The training certification shall specify the date on which
the training was received. All course materials shall be retained in compliance with Section VII
below.
5. Comprehensive shall review the training annually, and, where appropriate, update the training
to reflect changes in Federal law or HHS guidance, any issues discovered during internal or
external audits or reviews, and any other relevant developments.
6. Comprehensive shall not provide access to ePHI to any workforce member if that workforce
member has not signed or provided the written or electronic certification required by
paragraph V.G.4 within a reasonable period of time after completion of such training.
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VI. Implementation Report and Annual Reports
A. Implementation Report. Within one hundred and twenty (120) days after the receipt of HHS’
approval of the policies and procedures required by Section V.C., Comprehensive 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:
1. An attestation signed by an owner or officer of Comprehensive attesting that the Policies and
Procedures are being implemented, have been distributed to all appropriate members of the
workforce, and that Comprehensive has obtained all the compliance certifications in
accordance with paragraphs V.D.2 and V.D.3, if needed.
2. 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, if needed.
3. An attestation signed by an owner or officer of Comprehensive attesting that all workforce
members have completed the initial training required by this CAP and have executed the
training certifications required by Section V.D.2, where appropriate.
4. An attestation signed by an owner or officer of Comprehensive listing all Comprehensive
locations (including locations and mailing addresses), the corresponding name under which
each location is doing business, the corresponding phone numbers, and fax numbers, and
attesting that each such location has complied with the obligations of this CAP; and
5. An attestation signed by an owner or officer of Comprehensive 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.
B. Annual Reports. The one-year beginning on the Effective Date and each subsequent one-year
period during the period of compliance obligations shall be referred to as “the Reporting Periods.”
Comprehensive also shall submit to HHS Annual Reports with respect to the status of and findings
regarding Comprehensive’s compliance with this CAP for each of the two (2) year Reporting
Periods. Comprehensive shall submit each Annual Report to HHS no later than sixty
(60) days after the end of each corresponding Reporting Period. The Annual Report shall include:
1. A schedule, topic outline, and copies of the training materials for the training programs
attended, where applicable, in accordance with this CAP during the Reporting Period that is
the subject of the report.
2. An attestation signed by an owner or officer of Comprehensive 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.
3. A summary of Reportable Events (defined in Section V.F) identified during the Reporting
Period and the status of any corrective and preventative action relating to all such Reportable
Events, if applicable.
4. An attestation signed by an owner or officer of Comprehensive 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.
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VII. Document Retention
Comprehensive 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
Comprehensive is expected to fully and timely comply with all provisions contained in this CAP.
A. Timely Written Requests for Extensions
Comprehensive 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. The requirement may be waived by OCR only.
B. Notice of Breach of this CAP and Intent to Impose Civil Monetary Penalty.
The parties agree that a breach of this CAP by Comprehensive constitutes a breach of the
Agreement. Upon a determination by HHS that Comprehensive has breached this CAP, HHS may
notify Comprehensive of (1) Comprehensive’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”).
C. Comprehensive Response.
Comprehensive 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:
1. Comprehensive is in compliance with the obligations of the CAP that HHS cited as the
basis for the breach.
2. The alleged breach has been cured; or
3. The alleged breach cannot be cured within the thirty (30) calendar day period, but that: (a)
Comprehensive has begun to take action to cure the breach; (b) Comprehensive is pursuing
such action with due diligence; and (c) Comprehensive has provided to HHS a reasonable
timetable for curing the breach.
D. Imposition of CMP.
If at the conclusion of the thirty (30) calendar day period, Comprehensive 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 Comprehensive 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 Comprehensive in writing
of its determination to proceed with the imposition of a CMP pursuant to 45 C.F.R. Part 160.
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For Comprehensive
/s
Dr. Gene Zitser
Comprehensive Neurology, PC
2/7/2025
Date
For United States Department of Health and Human Services
/s
Linda C. Colón, Regional Manager
Eastern and Caribbean Region
Office for Civil Rights
2/10/2025
Date