SAMPLE POLICY WORK

Verification: The IT department conducts routine assessments of digital transmission protocols and encryption settings. External audits may also verify that our secure transmission practices comply with HIPAA and state mandates.

5. Reporting Breaches and Violations

Purpose: Prompt reporting and thorough investigation of any suspected or confirmed breaches of confidentiality are critical to mitigating harm, addressing vulnerabilities, and maintaining compliance with regulatory requirements.

Procedures:

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Immediate Notification: Staff who discover a breach or suspected breach must immediately notify their direct supervisor and the designated Privacy Officer. For urgent matters, telephone notification is required within 15 minutes, followed by a formal written report within 24 hours. • Incident Reporting System: All breaches are documented using the Incident Report Form and entered into the Secure Electronic Incident Management System (SEIMS). This system captures the details of the breach, the affected records, the nature of the incident, and the immediate corrective actions taken. • Investigation and Remediation: The Privacy Officer, together with the Quality Assurance and IT teams, conducts a thorough investigation to identify the root cause of the breach. Corrective actions are developed and implemented promptly. • Regulatory Notification: If a breach involves more than 500 individuals or meets criteria set forth by HIPAA’s Breach Notification Rule, external regulatory agencies (e.g., state health departments, the Office for Civil Rights) are notified within the prescribed timeframes. • Corrective Action Plan (CAP): A formal CAP is developed and executed, detailing remedial measures to prevent future breaches. The CAP is monitored through regular follow ‑ up and effectiveness reviews. • Documentation and Audit Trail: Every step from breach detection to investigation and remediation is documented in the SEIMS with complete audit trails. All documentation is retained for at least seven years for regulatory review. Verification: Quality Assurance and Compliance Teams review all breach incidents and CAP outcomes monthly, verifying that corrective actions are effective and that no repeat issues occur. The IT department provides logs of system breaches and resolution timelines.