Federal government advisory to hospitals concerning purported JCAHO surveyors, government agents and other imposters

by Thomas H. Taylor, Attorney, Johns, Flaherty & Collins

On May 23, 2005, the Nuclear Regulatory Commission (“NRC”) issued an advisory to hospitals and other health care organizations that possess NRC-licensed materials and equipment. Briefly, the federal government has identified and is concerned about a number of suspicious incidents that have occurred at hospitals in Arizona, California, Indiana, Massachusetts, Michigan, New Jersey, New York and Texas since last November. The purpose of this client alert is to update your hospital concerning this potential threat to the security of your organization and its staff and patients.

Suspicious Incidents

Since November 2004, there have been a number of suspicious incidents around the country involving male and female suspects attempting to gain access to hospitals by posing as federal agents or Joint Commission for Accreditation of Healthcare Organization (“JCAHO”) surveyors. The federal government has been unable to establish any link between these reported incidents and a specific, credible threat of an al-Qaida-related terrorist attack. Nonetheless, the Department of Homeland Security has expressed concern that these activities may exhibit characteristics of criminal activity or possibly pre-operational planning. The reported incidents include, for example:

1. A hospital in New York encountering two subjects who entered the hospital, identified themselves as special agents from the Department of Defense and the Central Intelligence Agency, and inquired about the hospital’s capacity for cardiac and trauma care, helicopter pads and private rooms.

2. A New Jersey hospital experiencing four incidents over a six-week period involving subjects who attempted to gain access to the hospital by posing as physician surveyors from the JCAHO.

3. Hospitals in Boston, Detroit and Los Angeles encountering male and female subjects who attempted to gain access to their premises by posing as JCAHO inspectors.

4. Hospitals in Arizona, Texas and Indiana encountering subjects who requested information concerning the location of their pharmacies, with each hospital being a known distribution point for antidote medicines used to counter biological attacks.

5. Hospitals in Arizona encountering subjects who requested photographs, building plans, the location of their pharmacies, and information about computer fraud.

Protective Measures Recommended By Federal Government

Concerned about the potential threat to hospitals and their staff and patients, the federal government is suggesting that hospitals across the country consider a number of protective measures. Suggested precautions include, for example:

1. Educating medical and other staff concerning the potential of unauthorized personnel presenting seemingly legitimate identification and credentials to gain access to your hospital;

2. Encouraging your employees to confront all suspicious individuals, particularly those who present to sensitive areas such as laboratories, pharmacies, physical plants and shipping and receiving;

3. Controlling and monitoring all entrances and exits to your hospital with closed circuit television, and implementing card access technology for areas beyond the main entrance;

4. Implementing strict credentialing and requiring identification badges for all of your hospital’s employees, contractors, official visitors and other persons;

5. Prohibiting information sharing with purported JCAHO representatives without first contacting your hospital’s administration and senior security staff;

6. Requiring photograph identification of and verifying the identities of purported JCAHO surveyors;

7. Securing and locking all areas in your hospital that are not open to the public including pharmaceutical storage areas, laboratories, cleaning supply closets and HVAC and utility equipment areas; and

8. Increasing the inspection and inventorying of sensitive materials and equipment in your hospital including, for example, pharmaceuticals and radiological material.

The enclosed NRC advisory and Department of Homeland Security information bulletin specify additional precautions that should be considered by your hospital and other health care organizations.

Key Impact On Hospitals And Health Care Organizations.

Although more than three and a half years have gone by since the devastating attack on the twin towers of the World Trade Center in New York, the federal government remains concerned about the potential for another terrorist attack. The NRC advisory issued on May 23, 2005 is not the first time that the federal government has expressed concern for the safety of our country’s hospitals and health care system.

Johns, Flaherty & Collins, S.C. encourages your hospital to carefully review the enclosed NRC advisory and accompanying Department of Homeland Security information bulletin. Regardless of the potential risk of future terrorist activities in your community, the precautions suggested by the NRC and the Department of Homeland Security provide a sound framework for assessing your hospital’s current security and potential corrective measures.

If you have any questions about this matter, please contact Thomas H. Taylor at (608) 784-5678.