Breach Notification
Sets how the Agency finds, assesses and reports a breach of clients' unsecured protected health information under the HIPAA Breach Notification Rule (the four-factor risk assessment, notice to each affected person without unreasonable delay and no later than 60 calendar days after discovery, media notice for more than 500 residents of a state, and notice to HHS), how it handles a breach of employees' or clients' Social Security, driver's license or financial account numbers under Michigan's Identity Theft Protection Act, and how every incident is logged.
- Policy number
- MI-HC-PRV-03
- Version
- 1.0
- Main rule
- 45 CFR §164.404
- Library
- Michigan home care · 50 policies
- Category
- Privacy
- Sections
- 18
In short
- A lost phone or file, or information sent to the wrong person, may be a breach.
- Tell the privacy official the same day. Do not try to fix it quietly.
- Help contain it: ask the wrong recipient to delete or return the information.
- The privacy official decides whether it is a breach and sends any notices on time.
- Clients must be told no later than 60 days after a breach is discovered, so speed matters.
What's inside
18 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 and Contain (Same Day)
- 6. Step 2: Decide Whether It Is a HIPAA Breach
- 7. Step 3: Give the HIPAA Notices
- 8. Law Enforcement Delay
- 9. Michigan Identity Theft Protection Act
- 10. Step 4: Log, Correct and Report
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- A caregiver texted a client's schedule to the wrong person. Walk me through what you would do.
- How do you decide whether an incident is a reportable breach?
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