Breach Notification
Sets out what the Agency does when client or staff information may have been lost, stolen or wrongly shared: immediate reporting and containment, the HIPAA four-factor risk assessment, notice to individuals, the media and HHS within the federal time limits, and notice to Louisiana residents and the Attorney General under R.S. 51:3074 and LAC 16:III.701.
About this policy
- Policy number
- LA-HC-PRV-03
- Version
- 1.0
- Main rule
- 45 CFR §164.404
- Library
- Louisiana home care · 50 policies
- Category
- Privacy
- Sections
- 21
In short
- If client or staff information is lost, stolen, seen by the wrong person or sent to the wrong place, tell your supervisor and the privacy official at once.
- Do not investigate on your own and do not delete anything.
- The Agency decides whether it is a breach and must notify affected people no later than 60 days after discovery.
- Louisiana law also requires notice to affected residents and to the Attorney General.
- Reporting quickly protects clients and is never punished.
What's inside
21 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (45 CFR §164.404)
- 5. Step 1: Report at Once
- 6. Step 2: Contain and Mitigate
- 7. Step 3: Decide Whether It Is a HIPAA Breach
- 8. Step 4: Notify Affected Clients
- 9. Step 5: Notify the Media and HHS
- 10. Law Enforcement Delay
- 11. Louisiana Notice Requirements
- 12. Breaches by Business Associates
- 13. After the Breach
- 14. Responsibilities
- 15. Records and Compliance Monitoring
- 16. Staff Training
- 17. References
- 18. Related Policies and Forms
- 19. Approval
- 20. Revision History
An inspector may ask
- What does a worker do if a phone with client information is lost or a document is sent to the wrong person?
- Show me your breach log and the risk assessment for this incident.
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