SAMPLE POLICY WORK

– The employee must contact their immediate supervisor and the Privacy Officer immediately upon discovering a breach. – In cases where client safety is at risk, emergency protocols are activated concurrently. 2. Incident Documentation: – Complete an Incident Report Form within 24 hours detailing the breach, including addressed data, time, location, involved parties, and initial corrective steps. – Submit the form via the Secure Electronic Incident Management System (SEIMS). 3. Investigation and Remediation: – The Privacy Officer and IT support conduct an investigation to identify the source of the breach, including a root cause analysis. – Develop a corrective action plan to remediate vulnerabilities. This plan includes immediate technical fixes, adjustments to employee protocols, and additional training if necessary.

Notification of Affected Parties:

– If the breach involves personal or health information of a significant number of individuals, follow regulatory guidelines to notify affected parties and relevant regulatory agencies. – Communicate corrective measures and preventive actions taken to restore confidence and compliance. 5. Closure and Follow-Up: – Once all corrective measures are verified, the incident is marked as “closed” in the SEIMS. – A comprehensive report is generated, and lessons learned are integrated into the next round of staff training and policy updates.

e. Training and Compliance on Confidentiality

Ensuring that all staff understand and adhere to confidentiality protocols is vital. Training on confidentiality is integrated into the orientation and ongoing professional development programs:

Initial Confidentiality Training:

– Every new hire receives mandatory confidentiality training during orientation. This training covers: • Fundamental principles of HIPAA, HITECH, and state privacy laws. • Procedures for secure data collection, storage, transmission, and destruction.