HIPAA Compliance Policy for Bala Better Health

Purpose

The purpose of this policy is to establish and maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) to safeguard the privacy, security, and integrity of Protected Health Information (PHI) handled by Bala Better Health. All staff, contractors, and affiliates are expected to adhere to these guidelines to ensure patient trust and compliance with federal law.

Scope

This policy applies to all employees, contractors, vendors, and business associates of Bala Better Health who have access to or handle PHI. It covers all forms of PHI, including electronic, paper-based, and verbal communications.

Key Definitions

  • PHI (Protected Health Information): Any individually identifiable health information transmitted or maintained in any form.
  • ePHI: Electronic Protected Health Information.
  • Business Associate: Any third-party entity that handles PHI on behalf of Bala Better Health.
  • Minimum Necessary Standard: Limiting PHI use and disclosure to the minimum required to accomplish the intended purpose.

Policy Guidelines

1. Privacy Rule Compliance

  • Use and Disclosure of PHI: PHI will only be used or disclosed as permitted under HIPAA, including:
    • For treatment, payment, or healthcare operations.
    • With patient authorization.
    • As required by law.
  • Patient Rights:
    • Patients have the right to access, amend, and request restrictions on their PHI.
    • Patients will receive a Notice of Privacy Practices (NPP) outlining their rights and Bala Better Health’s practices regarding PHI.
  • Authorization Requirements:
    • PHI will not be shared with third parties without prior written authorization from the patient, except as allowed by law.

2. Security Rule Compliance

  • Access Controls:
    • Access to PHI is restricted to authorized personnel based on job duties.
    • Unique user IDs and passwords are required for all electronic systems containing ePHI.
  • Data Protection:
    • PHI is encrypted during electronic transmission and storage.
    • Physical records are stored in locked cabinets or rooms with controlled access.
  • Device and Media Management:
    • All devices used to access PHI are password-protected and include encryption where possible.
    • Data on obsolete or retired devices is securely erased.
  • Workstation Security:
    • Workstations used to access PHI are located in secure areas and are logged off when unattended.

3. Breach Notification and Incident Response

  • Breach Reporting:
    • Any suspected or confirmed breach of PHI must be reported immediately to the Compliance Officer.
    • Breaches affecting more than 500 individuals will be reported to the U.S. Department of Health and Human Services (HHS) and affected patients within 60 days.
  • Incident Response:
    • An investigation will be conducted for all reported breaches.
    • Appropriate measures, including remediation and notification, will follow based on the investigation findings.

4. Training and Awareness

  • Employee Training:
    • All employees will receive HIPAA training upon hire and annually thereafter.
    • Training will include HIPAA regulations, Bala Better Health’s policies, and best practices for PHI protection.
  • Acknowledgment of Policy:
    • All employees and contractors must acknowledge and agree to comply with HIPAA policies and procedures.

5. Business Associate Agreements (BAAs)

  • Requirement for BAAs:
    • Bala Better Health will execute BAAs with all third-party vendors or business associates who handle PHI.
    • BAAs will specify responsibilities for safeguarding PHI and include provisions for breach notification.

6. Minimum Necessary Standard

  • PHI access and disclosure are limited to the minimum amount necessary to perform job duties or fulfill requests.

7. Physical Security

  • Facility Security:
    • Restricted areas where PHI is stored or processed are accessible only to authorized personnel.
    • Visitors must sign in and be escorted while in restricted areas.
  • Paper Records:
    • Documents containing PHI are securely stored and shredded when no longer needed.

8. Administrative Safeguards

  • Compliance Officer:
    • A designated Compliance Officer is responsible for HIPAA compliance oversight, training, and breach response.
  • Risk Assessments:
    • Regular risk assessments will identify and mitigate vulnerabilities in systems and processes handling PHI.

Sanctions and Disciplinary Actions

  • Employees who fail to comply with this HIPAA policy may face disciplinary action, including termination.
  • Contractors and business associates violating HIPAA policies may have contracts terminated and may be reported to regulatory authorities.

Policy Updates

  • This policy will be reviewed and updated annually or as necessary to reflect changes in regulations or business practices.

Acknowledgment

All staff, contractors, and business associates must acknowledge receipt and understanding of this policy. By signing, individuals affirm their commitment to adhere to Bala Better Health’s HIPAA Compliance Policy.

By following this comprehensive HIPAA Compliance Policy, Bala Better Health will protect patient information, maintain regulatory compliance, and uphold the trust of its clients and stakeholders.

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