Breach Notification
Explains what happens when patient information is lost, stolen, sent to the wrong person or seen by someone who should not see it: staff report it the same day, the Privacy Official assesses it, and the Agency notifies every individual, the federal government, the Texas Attorney General, the media and consumer reporting agencies when and as the law requires.
About this policy
- Policy number
- TX-HSP-PRV-03
- Version
- 1.0
- Main rule
- 45 CFR Part 164 Subpart D
- Library
- Texas hospice · 59 policies
- Category
- Privacy
- Sections
- 17
In short
- If patient information is lost, stolen, sent to the wrong person or seen by someone who should not see it, report it the same day.
- Report even if you are not sure anything is wrong. The Privacy Official decides what happens next.
- Help get the information back: ask the wrong person to return or destroy it and tell the office.
- The law sets strict deadlines to notify patients and the government, so never wait.
What's inside
17 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 §§164.400-164.414; Tex. Bus. & Com. Code §521.053)
- 5. Risk Assessment
- 6. Federal Notices
- 6.1 Content and method of notice to individuals
- 7. Texas Notices
- 8. Business Associates and Law Enforcement Delay
- 9. Procedure
- 10. Responsibilities
- 11. Records and Compliance Monitoring
- 12. References
- 13. Related Policies and Forms
- 14. Approval
- 15. Revision History
An inspector may ask
- A nurse’s bag with a visit sheet is stolen from her car. Walk me through what happens next.
- Show me the risk assessment for your most recent incident, or your log showing you had none.
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