Compliance & Privacy (HIPAA)
For: OneCare Health Associates
Effective Date: 2024
Approved By: Dalynes Cancel
1. Purpose
These policies establish the standards and procedures required for [Organization Name] to comply with the Health Insurance Portability and Accountability Act (HIPAA), including the Privacy Rule, Security Rule, and Breach Notification Rule.
2. Scope
These policies apply to:
- All employees, contractors, interns, and third-party vendors
- All systems, applications, and processes that store, transmit, or process Protected Health Information (PHI)
- All physical locations where PHI is accessed or stored
3. Definitions
- PHI: Individually identifiable health information in any form (electronic, paper, verbal).
- ePHI: PHI stored or transmitted electronically.
- Minimum Necessary: Limiting PHI use/disclosure to the least amount needed.
- BAA (Business Associate Agreement): Required agreement with any entity handling PHI on behalf of the organization.
4. HIPAA Privacy Policy
4.1 Use & Disclosure of PHI
PHI may only be used or disclosed for:
- Treatment, payment, and healthcare operations (TPO)
- Uses permitted or required by law
- Uses authorized by the patient via a signed HIPAA authorization form
4.2 Minimum Necessary Access
- Workforce members receive only the level of PHI access necessary for their job role.
- Systems and applications must enforce role-based access controls (RBAC).
4.3 Patient Rights
Patients may:
- Access or request copies of their PHI
- Request amendments to their records
- Request a restriction or confidential communication
- Receive an accounting of disclosures
Requests must be processed within HIPAA-required timelines.
4.4 Notice of Privacy Practices (NPP)
- An NPP must be provided to patients or clients.
- The organization must maintain documented acknowledgment.
5. HIPAA Security Policy
5.1 Administrative Safeguards
- • Conduct an annual HIPAA Risk Assessment.
- • Assign a HIPAA Privacy Officer and HIPAA Security Officer.
- • Enforce workforce training annually and upon onboarding.
- • Implement sanctions for non-compliance.
5.2 Physical Safeguards
- Access to areas with PHI is restricted by badge, key, or equivalent.
- Workstations must auto-lock after inactivity.
- Paper PHI must be secured in locked cabinets.
- A clean-desk policy is required.
5.3 Technical Safeguards
- All ePHI must be encrypted in transit (TLS 1.2+) and at rest (AES-256).
- Unique user IDs and multi-factor authentication (MFA) must be used.
- Access logs must be retained for at least 6 years.
- Systems must be monitored for unauthorized access attempts.
- Regular backups of ePHI must be performed and tested.
6. Breach Notification Policy
6.1 Definition of a Breach
A breach occurs when PHI is accessed, acquired, used, or disclosed in a manner not permitted under HIPAA.
6.2 Breach Response Process
- Immediate reporting to the Security Officer (within 24 hours).
- Investigation using a documented incident response procedure.
- Risk assessment to determine whether PHI was compromised.
Notifications (if breach is confirmed):
- Patients: Within 60 days
- HHS OCR: Immediately for breaches affecting 500+ individuals, or annually for fewer
- Media: If 500+ individuals in a geographic region are affected
6.3 Breach Documentation
All incidents, whether breaches or not, must be documented and retained for 6 years.
7. Business Associate Management
- BAAs must be executed with all vendors handling PHI.
- Vendors must undergo due diligence reviews.
- BAAs must outline permitted uses of PHI, safeguards, and breach responsibilities.
8. Workforce Training Policy
- New employees must complete HIPAA training within 30 days of hire.
- Annual refresher training is mandatory.
- Specialized training required for employees with high-risk roles (billing, IT, clinical).
9. Device & Media Control Policy
- All devices containing ePHI must be inventoried.
- Portable devices (laptops, USB drives, phones) must be encrypted.
- PHI must be securely disposed of (shredding, certified destruction, secure wiping).
10. Contingency Planning Policy
Required elements:
- Data backup plan
- Disaster recovery plan
- Emergency mode operation plan
- Periodic testing and revision of plans
11. Auditing & Monitoring Policy
- Regular system and access audits performed at least quarterly.
- Random PHI access reviews conducted to detect inappropriate behavior.
- Audit logs cannot be modified or deleted.
12. Sanctions Policy
• Violations of HIPAA policies result in disciplinary actions:
- Verbal or written warning
- Suspension
- Termination
- Legal consequences (if applicable)
13. Policy Review & Updates
- HIPAA policies must be reviewed annually or upon changes in law or operations.
- The Privacy/Security Officer must document all revisions.
