Breach Notification
Sets how the Agency finds, assesses and reports breaches of unsecured protected health information under the HIPAA Breach Notification Rule (45 CFR §§164.400 to 164.414): reporting a possible breach at once, the four-factor risk assessment, notice to patients without unreasonable delay and no later than 60 calendar days after discovery, notice to the media and to the Secretary of Health and Human Services, law enforcement delay, business associate breaches, and why the Ohio data breach law, ORC 1349.19, does not apply to the Agency as a HIPAA covered entity.
- Policy number
- OH-HSP-PRV-03
- Version
- 1.0
- Main rule
- 45 CFR §164.400-414
- Library
- Ohio hospice · 60 policies
- Category
- Privacy
- Sections
- 21
In short
- If patient information goes to the wrong person or is lost, tell your supervisor and the privacy official at once.
- Do not delete anything; ask the person who received it to return or destroy it.
- The privacy official decides whether it is a breach and sends any required notices.
- Patients must be told without unreasonable delay and no later than 60 days after the breach is discovered.
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 §§164.400-414)
- 5. Report at Once
- 6. Is It a Breach?
- 6.1 The four-factor risk assessment
- 7. Notice to Patients
- 8. Notice to the Media and to the Secretary of Health and Human Services
- 9. Law Enforcement Delay
- 10. Breaches by Business Associates
- 11. Containment, Mitigation and Prevention
- 12. The Ohio Data Breach Law
- 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
- What do your staff do if they send a patient's record to the wrong fax number?
- How do you decide whether an incident is a reportable breach?
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