Green Ridge Behavioral Health LLC Resolution Agreement and Corrective Action Plan HHSgov
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ppResolution AgreementppI RecitalsppII Terms and ConditionsppFor Green Ridge Behavioral HealthppsppDr Samina Yousufi Ownerpp10302023ppDateppFor the United States Department of Health and Human ServicesppsppJamie Rahn Ballay
Regional Manager
Office for Civil Rightspp10312023ppDateppCorrective Action PlanppBetween theppUS Department of Health and Human ServicesppAndppGreen Ridge Behavioral HealthppI PreambleppGreen Ridge Behavioral Health LLC GRBH 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 GRBH is entering into a Resolution Agreement Agreement with HHS and this CAP is incorporated by reference into the Resolution Agreement as Appendix A GRBH enters into this CAP as part of consideration for the release set forth in paragraph ll8 of the AgreementppII Contact Persons and SubmissionsppGRBH 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 reportsppDr Samina Yousufi
Owner GRBH
610 Professional Drive Suite 255
Gaithersburg MD 20879syousuigreenridgebhcom
Phone 2406836202
Fax 2406836203ppHHS has identified the following individual as its authorized representative and contact person with whom GRBH is to report information regarding the implementation of this CAPppJamie Rahn Ballay Regional Manager
MidAtlantic Region
Office for Civil Rights
US Department of Health and Human ServicesppGRBH and HHS agree to promptly notify each other of any changes in the contact persons or the other information provided aboveppIII Effective Date and Term of CAPppThe Effective Date for this CAP shall be calculated in accordance with paragraph II14 of the Agreement Effective Date The period for compliance Compliance Term with the obligations assumed by GRBH under this CAP shall begin on the Effective Date of this CAP and end three 3 years from the Effective Date unless HHS has notified GRBH under Section VIII hereof of its determination that GRBH breached this CAP In the event HHS notifies GRBH of a breach under section VIII hereof the Compliance Term shall not end until HHS notifies GRBH that HHS has determined GRBH failed to meet the requirements of section VTIIC of this CAP and issues a written notice of intent to proceed with an imposition of a civil money penalty against GRBH pursuant to 45 CFR Part 160 After the Compliance Term ends GRBH 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 Nothing in this CAP is intended to eliminate or modify GRBHs obligation to comply with the document retention requirements in 45 CFR 1643 16b and 1645300ppIV TimeppIn 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 daysppV Corrective Action ObligationsppGRBH agrees to the followingppB Policies and ProceduresppC Distribution and Updating of Policies and ProceduresppD Minimum Content of the Policies and ProceduresppE Reportable EventsppF TrainingppG Business Associate AgreementsppVI Implementation Report and Annual ReportsppA Implementation Report Within one hundred twenty 120 days after HHS approves GRBHs HIPAA training materials for workforce members specified in Section VF above GRBH shall submit a written report with the documentation described below to HHS for review and approval Implementation Repo rt The Implementation Report shall includeppB Annual Reports The oneyear period beginning on the Effective Date and each subsequent oneyear period during the course of the period of compliance obligations shall be referred to as the Reporting Periods GRBH also shall submit to HHS Annual Reports with respect to the status of and findings regarding GRBHs compliance with this CAP for each of the two 2 Reporting Periods GEBH shall submit each Annual Report to HHS no later than sixty days after the end of each corresponding Reporting Period The Annual Report shall includeppVII Document RetentionppGRBH 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 DateppVIII Breach ProvisionsppGRBH is expected to fully and timely comply with all provisions contained in this CAPppA Timely Written Requests for Extensions
GRBH 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 days prior to the date such an act is required or due to be performed This requirement may be waived by OCR onlyppB Notice of Breach of this CAP and Intent to Impose Civil Monetary Penalty
The parties agree that a breach of this CAP by GRBH constitutes a breach of the Agreement Upon a determination by HHS that GRBH has breached this CAP HHS may notify GRBH of I GRBHs breach and 2 HHS intent to impose a CMP pursuant to 45 CFR Part 160 or other remedies for the Covered Conduct set forth in paragraph 12 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 CMPppC GRBHs Response
GRBH 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 thatppD Imposition of CMP
If at the conclusion of the thirtyday period GRBH fails to meet the requirements of Section VIIIC of this CAP to HHSs satisfaction HHS may proceed with the imposition of the CMP against GRBH pursuant to 45 CFR Part 160 for any violations of the Covered Conduct set forth in paragraph I2 of the Agreement and for any other act or failure to act that constitutes a violation of the HIPAA Rules HHS shall notify GRBH in writing of its determination to proceed with the imposition of the CMP pursuant to 45 CFR Part 160ppFor Green Ridge Behavioral HealthppsppDr Samina Yousufi
OwnerppDate October 30 2023ppFor United States Department of Health and Human ServicesppsppJamie Rahn Ballay
Regional Manager
Office for Civil RightsppDate October 31 2023ppReceive the latest updates from the Secretary Blogs and News Releasespp200 Independence Avenue SW
Washington DC 20201
Toll Free Call Center 18776966775p
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ppResolution AgreementppI RecitalsppII Terms and ConditionsppFor Green Ridge Behavioral HealthppsppDr Samina Yousufi Ownerpp10302023ppDateppFor the United States Department of Health and Human ServicesppsppJamie Rahn Ballay
Regional Manager
Office for Civil Rightspp10312023ppDateppCorrective Action PlanppBetween theppUS Department of Health and Human ServicesppAndppGreen Ridge Behavioral HealthppI PreambleppGreen Ridge Behavioral Health LLC GRBH 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 GRBH is entering into a Resolution Agreement Agreement with HHS and this CAP is incorporated by reference into the Resolution Agreement as Appendix A GRBH enters into this CAP as part of consideration for the release set forth in paragraph ll8 of the AgreementppII Contact Persons and SubmissionsppGRBH 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 reportsppDr Samina Yousufi
Owner GRBH
610 Professional Drive Suite 255
Gaithersburg MD 20879syousuigreenridgebhcom
Phone 2406836202
Fax 2406836203ppHHS has identified the following individual as its authorized representative and contact person with whom GRBH is to report information regarding the implementation of this CAPppJamie Rahn Ballay Regional Manager
MidAtlantic Region
Office for Civil Rights
US Department of Health and Human ServicesppGRBH and HHS agree to promptly notify each other of any changes in the contact persons or the other information provided aboveppIII Effective Date and Term of CAPppThe Effective Date for this CAP shall be calculated in accordance with paragraph II14 of the Agreement Effective Date The period for compliance Compliance Term with the obligations assumed by GRBH under this CAP shall begin on the Effective Date of this CAP and end three 3 years from the Effective Date unless HHS has notified GRBH under Section VIII hereof of its determination that GRBH breached this CAP In the event HHS notifies GRBH of a breach under section VIII hereof the Compliance Term shall not end until HHS notifies GRBH that HHS has determined GRBH failed to meet the requirements of section VTIIC of this CAP and issues a written notice of intent to proceed with an imposition of a civil money penalty against GRBH pursuant to 45 CFR Part 160 After the Compliance Term ends GRBH 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 Nothing in this CAP is intended to eliminate or modify GRBHs obligation to comply with the document retention requirements in 45 CFR 1643 16b and 1645300ppIV TimeppIn 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 daysppV Corrective Action ObligationsppGRBH agrees to the followingppB Policies and ProceduresppC Distribution and Updating of Policies and ProceduresppD Minimum Content of the Policies and ProceduresppE Reportable EventsppF TrainingppG Business Associate AgreementsppVI Implementation Report and Annual ReportsppA Implementation Report Within one hundred twenty 120 days after HHS approves GRBHs HIPAA training materials for workforce members specified in Section VF above GRBH shall submit a written report with the documentation described below to HHS for review and approval Implementation Repo rt The Implementation Report shall includeppB Annual Reports The oneyear period beginning on the Effective Date and each subsequent oneyear period during the course of the period of compliance obligations shall be referred to as the Reporting Periods GRBH also shall submit to HHS Annual Reports with respect to the status of and findings regarding GRBHs compliance with this CAP for each of the two 2 Reporting Periods GEBH shall submit each Annual Report to HHS no later than sixty days after the end of each corresponding Reporting Period The Annual Report shall includeppVII Document RetentionppGRBH 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 DateppVIII Breach ProvisionsppGRBH is expected to fully and timely comply with all provisions contained in this CAPppA Timely Written Requests for Extensions
GRBH 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 days prior to the date such an act is required or due to be performed This requirement may be waived by OCR onlyppB Notice of Breach of this CAP and Intent to Impose Civil Monetary Penalty
The parties agree that a breach of this CAP by GRBH constitutes a breach of the Agreement Upon a determination by HHS that GRBH has breached this CAP HHS may notify GRBH of I GRBHs breach and 2 HHS intent to impose a CMP pursuant to 45 CFR Part 160 or other remedies for the Covered Conduct set forth in paragraph 12 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 CMPppC GRBHs Response
GRBH 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 thatppD Imposition of CMP
If at the conclusion of the thirtyday period GRBH fails to meet the requirements of Section VIIIC of this CAP to HHSs satisfaction HHS may proceed with the imposition of the CMP against GRBH pursuant to 45 CFR Part 160 for any violations of the Covered Conduct set forth in paragraph I2 of the Agreement and for any other act or failure to act that constitutes a violation of the HIPAA Rules HHS shall notify GRBH in writing of its determination to proceed with the imposition of the CMP pursuant to 45 CFR Part 160ppFor Green Ridge Behavioral HealthppsppDr Samina Yousufi
OwnerppDate October 30 2023ppFor United States Department of Health and Human ServicesppsppJamie Rahn Ballay
Regional Manager
Office for Civil RightsppDate October 31 2023ppReceive the latest updates from the Secretary Blogs and News Releasespp200 Independence Avenue SW
Washington DC 20201
Toll Free Call Center 18776966775p
