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Breach Notification

Explains how the Agency investigates a possible breach of patient information, decides whether notification is required under the HIPAA Breach Notification Rule, and notifies patients, the U.S. Department of Health and Human Services and, for large breaches, the media within the federal time limits, and how this relates to the Michigan Identity Theft Protection Act.

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About this policy
Policy number
MI-HSP-PRV-03
Version
1.0
Main rule
45 CFR Part 164, Subpart D
Library
Michigan hospice · 59 policies
Category
Privacy
Sections
20

In short

  • If patient information goes to the wrong person, or papers or a device are lost or stolen, tell Lee Sample right away.
  • Do not wait to find out if it is serious. The Agency decides that, and the clock starts when anyone at the Agency knows.
  • Help contain it: ask for papers back, report a theft to police, and let the Security Official lock or wipe the device.
  • Patients must be told no later than 60 days after the Agency finds out, and sooner when possible.

What's inside

20 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (45 CFR §164.404; MCL 445.72)
  • 5. Reporting an Incident Inside the Agency
  • 6. Assessment
  • 7. Notice to Patients
  • 8. Notice to the Media and to HHS
  • 9. Law Enforcement Delay
  • 10. Business Associates
  • 11. Michigan Personal Information That Is Not Patient Information
  • 12. After a Breach
  • 13. Responsibilities
  • 14. Records and Compliance Monitoring
  • 15. Staff Training
  • 16. References
  • 17. Related Policies and Forms
  • 18. Approval
  • 19. Revision History

An inspector may ask

  • A nurse's bag with visit notes was stolen from her car. Walk me through what you would do and the deadlines.
  • Show me your breach log for last year, and how you reported breaches affecting fewer than 500 people.

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