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Privacy Breach Nugget: When Patient “Success Stories” Become a Privacy Breach

Privacy Breach Nugget: When Patient “Success Stories” Become a Privacy Breach

​When Patient “Success Stories” Become a Privacy Breach

Privacy Breach Nugget

Ever wonder how privacy breaches happen—and what you can do to stop them? Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s unpack today’s case and explore what went wrong, what worked, and how you can apply these insights to protect patient information.

What Happened

Cadia Healthcare Facilities, which is a rehabilitation, skilled nursing, and long-term care services provider with 5 locations located in Delaware, US.

Cadia posted patient names, photographs, and detailed health information on its public-facing website as part of a marketing campaign featuring patient “success stories.” These disclosures were made without obtaining valid written authorization from the patients whose information appeared on the website.

4 Step Privacy Breach Response

Cadia’s management of the privacy breach can be examined using the 4 Step Response Plan framework.

Step 1 – Spot and Stop

Cadia had procedures that required employees to obtain a written consent from patients before sharing their testimonials. Despite this, the Office of Civil Rights (OCR) received a complaint in September 2021 alleging that patient information had been disclosed without authorization.

OCR’s investigation ultimately confirmed that the protected health information (PHI) of 150 patients had been disclosed without proper authorization. Cadia was formally notified of these findings in February 2022.

Step 2 – Investigate

Cadia conducted an internal investigation and on March 2022 removed all the success stories from their social media and website and ended the marketing campaign.

However, during this process, the organization deleted the content before confirming which patients had valid written consent on file, making it more difficult to accurately determine the full scope of unauthorized disclosures.

Step 3 – Notify

Cadia initially failed to notify affected patients of the privacy breach, as required. Notification obligations were later addressed as part of the enforcement process. A public notice regarding the breach can now be found on the Cadia website.

Step 4 – Prevent the Breach from Happening Again

According to the OCR settlement details:

  • Cadia agreed to pay a $182,000 USD penalty
  • A Corrective Action Plan (CAP) was imposed, including two years of OCR monitoring and reporting
  • Cadia failed to properly implement its existing administrative privacy policies
  • Cadia is required to:
    • Revise its privacy policies and procedures
    • Provide privacy training to all staff, including marketing personnel
    • Implement stronger authorization processes before using patient information for marketing
  • Cadia must now notify all affected individuals whose PHI was disclosed without authorization

 

Website and Social Media Tips

Custodians are responsible for ensuring that patients’ health information is collected, used, and disclosed in compliance with health privacy legislation, such as Alberta’s Health Information Act (HIA) and Ontario’s Personal Health Information Protection Act (PHIPA).

It’s also important to ensure your practices align with professional college standards related to advertising, professionalism, and confidentiality.

Here are key questions to include in your website and social media compliance checklist before collecting or using patient testimonials:

  • What is your clinic’s approval process before content is posted online?
  • Has the patient provided written consent for their information to be used?
    • If a photograph is included, does the consent explicitly authorize the use of images?
  • Who authorizes the content before it is published?
    • For example: the healthcare provider, lead custodian, social media lead, or privacy officer?
  • Before posting, has the content been reviewed for compliance with:
    • Health privacy legislation?
    • Professional college standards?
  • Does your marketing vendor understand your privacy obligations?
    • Do you have a written agreement in place requiring the vendor to protect the confidentiality of personal health information?

Also See

Is your website secure? Take the Website Self-Assessment from Elevated Business Solutions.

Do you have a website for your healthcare practice in Ontario? PHIPA Website Guide from Elevated Business Solutions will help you.

Take-Aways

The Cadia case is a reminder that policies alone are not enough. Clinics must ensure that privacy requirements are understood, followed in practice, and applied consistently across all teams, including marketing and external vendors. Taking the time to review your website and social media practices now can help prevent a costly and public privacy breach later.

You May Also Be Interested In

Medical Secretary Fined for Unauthorized Access And Disclosure to Health Information

3rd Largest Fine Ever Under the HIA

References

Cadia Healthcare Facilities. Notice of Success Story Incident. https://cadiahealthcare.com/wp-content/uploads/2025/06/Cadia_Notice-1.pdf

Health and Human Services. HHS’ Office for Civil Rights Settles HIPAA Investigation of Cadia Healthcare Facilities for Disclosure of Patients’ Protected Health Information. 2025Sept30. https://www.hhs.gov/press-room/ocr-settles-hipaa-with-cadia-healthcare-facilities.html

Help Me With HIPAA. Did Anyone Even Ask If It Was OK? – Ep 531 podcast. 2025Oct17 https://helpmewithhipaa.com/did-anyone-even-ask-if-it-was-ok-ep-531

Build a Strong Privacy Management Program for Your Clinic With These 5 Critical Modules

Build a Strong Privacy Management Program for Your Clinic With These 5 Critical Modules

Struggling to Learn Your Role As A Privacy Officer?

In many small healthcare practices, the privacy officer is also the clinic manager, healthcare provider, IT technician, or business owner. It’s no surprise that new privacy officers feel overwhelmed trying to balance competing responsibilities.

Without a clear plan, you may find that you

  • Panic when a patient asks for their information for access or correction.
  • Scramble when new employees and healthcare providers join your clinic . . .and suddenly realize that you never got around to providing privacy and cybersecurity awareness training.
  • Hope that your practice will not be tapped on the shoulder for a practice review by your college or the OIPC.
  • Ignore privacy breach and hope no one else notices.
  • Avoid difficult decisions with your owners / staff who insist on doing things their way – even when it is not privacy compliant.
  • Never get ‘review privacy impact assessment’ and ‘review privacy policies and procedures’ off of your to-do list.
  • Avoid discussing privacy and security with your EMR and computer networks managed service providers because you are unsure of what questions to ask and what types of answers you should receive.

If you don’t have a written privacy management program and action plan, you are missing the systems that prevent small issues from becoming privacy and security incidents.

The good news? Organizations with an active privacy officer and privacy management program are less likely to experience breaches and report better staff engagement and patient trust.

Privacy Is Good For Business

Strong privacy practices aren’t just about legal compliance. Policies, procedures, and systems improve communication, reduce risk, and support better decision-making.

A practical privacy management program creates accountability for the collection, use, and disclosure of health information, while demonstrating compliance to regulators and professional colleges.

Based on my experience, the five critical modules of a privacy management program are:

  1. Know Your Obligations
  2. Train
  3. Privacy Breach Management
  4. Document your Privacy Management Program
  5. Access and Disclosure

Module 1—Know your Obligations

Accountability starts with your healthcare provider(s)—also known as “custodians.” They are legally responsible for the privacy, confidentiality, and security of personal health information (PHI).

Custodians can delegate day-to-day tasks to a privacy officer, often the clinic or practice manager in smaller settings. Business owners also have obligations for employee and customer information. Together, the healthcare provider, business owner, and privacy officer form a trifecta of authority responsible for privacy compliance.

Knowing your obligations means:

  • Establishing clear roles and accountability
  • Identifying all types of personal and health information in your practice
  • Understanding how privacy legislation applies to your operations

Training for custodians and privacy officers is often required to build confidence and competence in these responsibilities.

Module 2 – Training

Privacy training is essential and must be consistent across your organization. Every staff member—new and experienced—should complete privacy awareness and cybersecurity training, and you should document attendance.

Effective training includes both formal and informal opportunities:

  • Formal: orientation programs, annual refreshers, and documented privacy awareness training
  • Informal: short reminders in staff meetings, activities tied to events like Data Privacy Day or Cybersecurity Awareness Month

Don’t overlook staff moving into new roles—promotions are an ideal time for targeted training about new responsibilities, such as authorizing users or supervising others.

Module 3 – Privacy Breach Management Plan

Every practice needs a written privacy breach management procedure. The privacy officer should ensure staff know how to recognize and report a breach, and custodians must be notified promptly.

Your plan should cover:

  • How to contain and investigate suspected breaches
  • Sanctions for non-compliance
  • Notification to patients and regulators when required

The privacy officer will manage mandatory privacy breach notification requirements under the health privacy legislation like the Alberta Health Information Act (HIA), Ontario Personal Health and Information Protection Act (PHIPA) and the Personal Information Protection of Electronic Documents Act (PIPEDA) and other province’s legislation.

Module 4 – Document: The Backbone of Privacy Compliance

Privacy training is essential and must be consistent across your organization. Every staff member—new and experienced—should complete privacy awareness and cybersecurity training, and you should document attendance.

Effective training includes both formal and informal opportunities:

  • Formal: orientation programs, annual refreshers, and documented privacy awareness training
  • Informal: short reminders in staff meetings, activities tied to events like Data Privacy Day or Cybersecurity Awareness Month

Don’t overlook staff moving into new roles—promotions are an ideal time for targeted training about new responsibilities, such as authorizing users or supervising others.

Module 5 – Access and Disclosure: Ensuring Patient Rights

Patients and employees have the right to access and correct their information. Release of information (ROI) policies and procedures are essential.

Your ROI plan should:

  • Define clear steps for handling requests
  • Train staff on how to respond appropriately
  • Align with legislation and college standards of practice

Doing this well helps you avoid complaints and breaches, improves efficiency, and strengthens patient trust.

Bringing It All Together

Being a privacy officer doesn’t have to feel overwhelming. With a structured privacy management program built on these five modules, you’ll have the systems to protect patients, support your staff, and strengthen your business.

If you’re a privacy officer in a healthcare practice and want practical strategies you can apply right away, join the upcoming Practical Privacy Officer Strategies training.

Training starts October 9, 2025

Register here https://informationmanagers.ca/ppo

Not sure if this is for you?

Send me an email and ask me! I’m happy to mentor you and help you assess your practice management and privacy compliance priorities.

Do You Want To Be A Confident Healthcare Privacy Officer?

Do You Want To Be A Confident Healthcare Privacy Officer?

Understanding the Role: What Is a Privacy Officer?

A privacy officer is a key employee in a healthcare organization who is named by the healthcare provider (custodian) and assigned the responsibility to oversee all activities related to the implementation of, and adherence to, the organization’s privacy practices, and to ensure operational procedures are in compliance with relevant privacy laws. The Privacy Officer monitors employees and systems about how information is collected, used, and disclosed and access to identifying information.

A privacy officer may be known by other titles like privacy compliance officer or a security officer.

If your healthcare business involves the collection, use, and disclosure of your clients’ and patients’ personal health information, a privacy officer is necessary in order to meet legislated requirements.

Consequences of Operating Without a Privacy Officer

Healthcare practices without a privacy officer often experience confusion about how patients’ personal health information should be collected, used, and disclosed. Patients may complain about lack of access to their personal health information. Without a named privacy officer to assume the responsibility to implement and monitor reasonable administrative, technical, and physical safeguards you are more likely to experience privacy and security incidents, privacy breaches, investigations, fines, and charges under the privacy legislation!

Case Studies: Real-world Implications of Privacy Officer Absence

In 2019, the British Columbia Office of the Information and Privacy Commissioner (OIPC) conducted a privacy audit of 22 medical clinics. OIPC auditors examined 22 clinics and found gaps in privacy management programs at several clinics, including the absence of a designated privacy officer, a lack of funding and resources for privacy and a failure to ensure that privacy practices keep up with technological advances.

Here’s another example. A complaint was made against a medical clinic with an employee suspected of accessing health information for an unauthorized purpose. The Alberta OIPC investigated and revealed confusion around the roles and responsibilities of privacy compliance among the custodians and the privacy officer. The OIPC determined that the custodian was in contravention of the regulation which requires custodians to ensure that their affiliates are aware of and adhere to the all of the custodian’s administrative, technical, and physical safeguards with respect to health information. 

Say No to Snooping: The Need for Privacy Enforcement

Employees are not aware of privacy requirements and engage in snooping into personal health information. Consequences of employee snooping include firing, charges under the Health Information Act and court ordered fines, jail time, probation, community service and more.

say not so snooping animation of thief taking papers from folder

Roles and Responsibilities of a Healthcare Privacy Officer

So, what does a privacy officer do? The roles and responsibilities of a privacy officer in a typical healthcare practices include the following:

  • Identify privacy compliance issues for the business.
  • Ensure privacy and security policies and procedures are developed and keep them up to date.
  • Ensure that everyone working at your clinic and your vendors are aware of their privacy obligations.
  • Monitor your clinic’s ongoing compliance with privacy legislation like the Health Information Act (HIA) in Alberta.
  • Provide advice and interpretation of related legislation for the business.
  • Respond to requests for access and corrections to personal information.
  • Ensure the security and protection of personal information in the custody or control of the business.
  • Act as the primary point of privacy and access contact for staff, patients, vendors, regulators and other stakeholders.
 

Introducing Practical Privacy Office Strategies Training

I want to help you become a confident healthcare privacy officer. And a guide (or a Jeannie ) to help you is a good thing.

Practical Privacy Officer Strategies will help you to assess your current PIA and privacy management program and plan your privacy compliance activities for the next year!

Practical Privacy Officer Strategies will help you to assess your current PIA and privacy management program and plan your privacy compliance activities for the next year!
5 Modules with Live 1-hour training and on-line mentoring will help you to build systems to monitor the routine tasks that will protect privacy and alert you to potential problems before they become privacy and security incidents.
 
How the training will be delivered:
  • Pre-recorded core training in each of the 5 modules. You watch the 1 hour video before the live coaching call.
  • Live 1 hour coaching call with practical case study, discussion, and accountability in each of the 5 modules.
  • Actionable plan with templates, tools, and resources to use what you learned.
  • Every module includes both WHY you need the information and HOW you should use the information.
 
Find Out More!
Privacy Principles Applies After Death

Privacy Principles Applies After Death

 

Privacy Principles Applies After Death

Are your staff looking at medical records when they shouldn’t be?

Many people have the mistaken impression they can look at a patient’s medical records as long as they don’t tell anyone else.

It’s not okay.

We continue to see examples of snooping where both seasoned and new healthcare providers and support staff don’t realize that looking at patient’s health information—even with good intentions—is a serious privacy violation.

As privacy lawyer Kate Dewhirst puts it

  • Privacy = Don’t look
  • Confidentiality = Don’t tell

Despite years of experience, many healthcare professionals still need a refresher on the basics. Privacy awareness training remains essential.

In this article, I am sharing an example of the Ontario’s Information Privacy Commissioner (IPC). This case involves a privacy complaint submitted by the family of a deceased individual. It’s a good reminder that whether you’re running a brand-new clinic or managing an established practice, it’s critical to understand your legal responsibilities and have systems in place to protect patient information.

What Happened

In 2014, a physician accessed a deceased patient’s health records while acting in his role as a coroner. The patient was also a family member. Soon after, the family alleged that the physician continued to access the individual’s personal health information (PHI) contrary to Ontario’s Personal Health Information Protection Act (PHIPA).

The family submitted a complaint to the hospital. Initially, the hospital’s response did not satisfy the family. The family filed a complaint to the Information and Privacy Commissioner (IPC) of Ontario.

The IPC started a complaint investigation.

privacy principles after death privacy breach incident scenario diagram

Privacy Complaint Investigation

Under PHIPA, the hospital is a health information custodian and the physician is an agent of the hospital.

During the IPC investigation, the physician admitted he “accessed the health information in response to his concern about the individual’s well-being.”

“I know now that proceeding in this way was misguided and wrong.” He would never disclose the information to anyone; that would be a violation of patient privacy and a breach of doctor – patient confidentiality.

He acknowledged he misunderstood the difference between:

• Privacy: The general right of every individual (living or deceased) to limit access to their health information.
• Confidentiality: The duty to not share that information once accessed.
• Circle of care / Need to know: You must only access information required to provide care at that moment.

4 Step Response Plan

When you have a privacy breach, follow these four steps to manage the privacy breach incident.

Step 1 – Spot and Stop the Breach

The family’s complaint prompted the hospital to begin the first step to spot and stop the breach.

Step 2 – Evaluate the Risks

An initial risk assessment was conducted, and after the IPC got involved, the hospital re-opened the investigation. They completed a comprehensive review and used audit log reporting tools to trace access.

Step 3 – Notify

The hospital eventually informed the family of the privacy breach—but the notification wasn’t timely. A more thorough and timely response could have helped address the family’s concerns more effectively.

Step 4 – Prevent the Breach From Happening Again

Following the breach, the hospital implemented several improvements:

  • Introduced a new auditing program that enhances its ability to detect unauthorized access.
  • Updated its Privacy and Confidentiality Policy, which applies to all agents of the hospital.
  • Launched mandatory annual electronic privacy training program for all staff, volunteers and learners. Physicians must complete this training as part of the annual reappointment process.
  • Strengthened the privacy warning on its electronic system, which warns users that unauthorized use of personal health information may result in disciplinary action.

privacy principles after death sanctions

The hospital’s Medical Advisory Committee also recommended disciplinary actions:

  • A three-month suspension of the physician’s hospital privileges
  • Three years of enhanced monitoring of his access to patient records
  • A requirement to present at Grand Rounds on privacy topics upon his return

The IPC concluded that the disciplinary consequences for the physician were sufficient in the circumstances.

Privacy Breach Nuggets You Need to Know

Privacy breaches are in the news every day. Here’s how you can be proactive to prevent privacy breach pain.

  • Go beyond policies—model good practices
  • Use real-life examples in staff meetings
  • Incorporate gamification and ongoing discussions to engage your team

Privacy awareness is everyone’s responsibility. Make sure your staff know what’s expected, what’s at risk, and what to do if something goes wrong.

If you need to start or update your privacy awareness training program, check out the on-line education Privacy Awareness in Healthcare: Essentials.

When we know better, we can do better…

I’ve helped hundreds of healthcare practices prevent privacy breach pain like this. If you would like to discuss how I can help your practice, just send me an email. I am here to help you protect your practice.

PRIVACY BREACH NUGGETS are provided to help you add a ‘nugget’ to your privacy education program. Share these with your staff and patients as a newsletter, poster, or staff meeting.

Jean L. Eaton, Your Practical Privacy Coach

References and Resources

Dewhirst, Kate. After Death: Who Can Access The Records Of A Patient After Death? May 7, 2019. https://katedewhirst.com/blog/2019/05/07/after-death-who-can-access-the-records-of-a-patient-after-death/

Ontario Information and Privacy Commissioner IPC Investigation Report PHIPA DECISION 74 HC15-4 Sault Area Hospital August 10, 2018.

Changes to Alberta’s Privacy Impact Assessment (PIA) Review Process

Changes to Alberta’s Privacy Impact Assessment (PIA) Review Process

 

PIA Review Process for Healthcare Practices In Effect Now

If you’re a clinic manager or privacy officer in Alberta, this is an important update for you. The Office of the Information and Privacy Commissioner (OIPC) has announced changes to the Privacy Impact Assessment (PIA) review process that will impact custodians under the Health Information Act (HIA), public bodies under the Freedom of Information and Protection of Privacy Act (FOIP Act), and private sector organizations under the Personal Information Protection Act (PIPA).

In Alberta, when a healthcare practice completes a PIA, it gets signed off internally by the custodian—whether that’s a physician, dentist, chiropractor, or another health professional. From there, the PIA is submitted to the OIPC for review. This review process has been a crucial step in ensuring that health information privacy is adequately protected. The OIPC issues a file number once the submission is received.

Starting October 1, 2024, the OIPC is streamlining its review process.

  • The OIPC will receive the PIA.
  • The PIA will be reviewed as it is submitted.
  • PIAs will no longer be ‘accepted’, ‘conditionally accepted’, or ‘not accepted’.
  • Instead, the PIA will be reviewed and a closing letter with comments and recommendations will be issued to the custodian.

One important detail: if the OIPC finds that your PIA is incomplete, they will close the file and notify you to consider re-submitting once the gaps are addressed.

It’s worth noting that the PIA requirements laid out in the OIPC Privacy Impact Assessment Requirements Guide (2010) are still valid. While changes are on the horizon, the OIPC has confirmed that the current guidelines remain applicable for the time being.

What This Means for You

If you’re a custodian under the HIA, you’re required to submit PIAs to the OIPC for review before implementing new administrative practices or information systems (HIA s.64). The key steps in the PIA process include:

1. Prepare health information privacy and security policies and procedures that comply with the HIA.
2. Conduct a privacy and security risk assessment and documenting any mitigation strategies
3. Complete the PIA using the OIPC’s format, which must be signed off by the healthcare custodian and the organization.
4. Submit the PIA to the OIPC for review. The custodian is encouraged to ensure the PIA is complete and thorough before submission.
5. Receive a closing letter from the OIPC with any comments or recommendations.

Also, PIAs submitted before October 1, 2024, but not yet reviewed by the OIPC, will still fall under the new process.

PIA Privacy Impact Assessment Pink Elephant Log

Need Help with Your PIA?

If you’re planning to introduce new technology, implement new systems, open a new clinic, or make amendments to your existing PIA—whether you’re moving from local servers to the cloud, relocating clinics, or adding new services—these changes could affect you.

Navigating the PIA process can feel like tackling the elephant in the room. But you don’t have to do it alone. If you need help with your PIA or guidance on amendments, visit InformationManagers.ca/PIA for support. We’re here to help you every step of the way.