What to Include in Your HIPAA Breach Notification

February 20, 2023 645 views No Comments 5 Shares
hipaa breach reporting
As a health provider or any organization handling protected health information (PHI), adhering to the regulations of HIPAA is critical. HIPAA sets high standards for protecting patients’ data and preserving privacy, but what happens if there is a HIPAA security breach? In this blog post, we will explore what you need to include when HIPAA breach reporting.

HIPAA Breach Notification Rule

The HIPAA Breach Notification Rule mandates that healthcare providers and covered entities must alert both the Department of Health and Human Services (HHS) and affected individuals in the case of a breach in data security. A breach of PHI is considered as any unauthorized access, usage, dissemination, or acquisition of protected health information. All notifications are to be made within 60 days and without unreasonable delay from the time of discovery.

Who Needs to Be Notified?

If a data breach happens, people affected must be notified promptly. This includes patients, health plan members and employees with information that has been exposed. Depending on the severity and size of the breach, it may also be necessary to inform the media. The HHS must be informed if more than 500 people are impacted by the incident. However, for smaller breaches with fewer than 500 individuals affected, simply document the event and report it to the HHS annually.

What to Include in the Breach Notification

Breach notifications must include specific information as required by the HIPAA Breach Notification Rule. This includes:

A brief description of what happened

This should include relevant facts such as the date of the HIPAA security breach and the type of information accessed.

The types of PHI that were involved:

During the breach, various types of protected health information (PHI) were compromised. This could include personal details such as names, addresses and Social Security numbers, as well as medical records and other sensitive information.

The steps individuals should take to protect themselves

Individuals affected by the breach should take steps to protect themselves from any further harm. These measures can include monitoring credit reports, changing passwords, placing fraud alerts on accounts, and other preventative measures.

A brief description of what you are doing to investigate the breach

Explain what steps you are taking to investigate the breach, including who is conducting the investigation, what measures are being taken to prevent further breaches, and what actions you are taking to mitigate the harm caused by the breach.

Contact information for the covered entity

Include contact information such as a telephone number and email address where individuals can reach out for more information.

Contact information for the HHS

Include contact information such as a telephone number and email address where individuals can reach out to the HHS office for civil rights in case of any questions or complaints. Neglecting this when HIPAA breach reporting could lead to further problems down the line.

A statement indicating whether law enforcement has been notified

A mention of whether law enforcement has been notified of the breach should be included. This should include the name of the relevant agency and any associated case numbers.

A statement indicating whether there is any potential harm to individuals as a result of the breach

If there is a chance that individuals could suffer harm due to the breach, it should be noted in the statement. This could include risks such as identity theft, financial loss, or damage to one’s reputation.

A statement indicating what steps the covered entity is taking to mitigate harm

If the covered entity is taking actions to minimize any possible damage, they should be acknowledged in a statement.

A statement indicating what steps the covered entity is taking to prevent future breaches

Include a statement regarding the steps the covered entity is taking to prevent future breaches. This should include any technical or organizational measures that have been implemented and any policies that are being updated.

Tips for Writing a HIPAA Breach Notification

Those writing a HIPAA breach notification should follow these simple tips:
  1. Utilize clear and straightforward language to explain the events of the breach, as well as the steps being taken to address it.
  2. Use words and sentences that are easy to understand, especially when discussing technical terms or difficult concepts.
  3. Be honest and open in regard to what occurred and the actions being taken to prevent similar incidents in the future.
  4. Offer guidance on how individuals can protect themselves from identity theft or other issues resulting from this breach.
  5. Maintain a professional tone when communicating with those affected, avoiding language that could come across as blaming or insulting them.

Final Thoughts

Encountering a HIPAA breach is never an easy situation. And performing HIPAA breach reporting is a complex process that requires due diligence and attention to detail. However, by adhering to the Breach Notification Rule and including all the necessary information in your notification, you can help ensure that those affected are informed of the incident promptly and respectfully. Additionally, being honest, and open and providing guidance on how to help protect one’s self will assist individuals in feeling more secure after a breach. To reduce any chance of a similar event reoccurring in the future, it is important to keep security protocols up-to-date, frequently assess risks, and educate staff members on HIPAA compliance. If you have any questions about HIPAA, get in touch with Spectra today to see how we can help!

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