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Institutional Handbook of Operating Procedures (IHOP)

Table of Contents
Official Governance

General Administrative
Employee Related
Fiscal Related
Faculty Related
Compliance Related
Student Policies
Health, Safety and Security


About IHOP (coming soon)

Description of the IHOP Process
Committee Members
Goals of the IHOP Committee
Process Diagram

Other Policies and Procedures

Departmental
Healthcare Epidemiology Policies

UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Policies

Subject 6.2 Privacy Related

Policy 6.2.5 Mitigation after Improper PHI Use or Disclosure

04/11/2003 - Originated

10/08/07 - Reviewed w changes

- Reviewed w/o changes

Compliance Office - Author

Mitigation after Improper Use or Disclosure of Protected Health Information (PHI)

Policy

UTMB, in an effort to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), maintains that patient information must be kept private and confidential.

UTMB has a duty to ensure the proper use and/or disclosure of PHI. To the extent practicable, UTMB will mitigate (i.e., lessen or alleviate) any harmful effect that becomes known to UTMB as a result of a use or disclosure of PHI by UTMB or its business associates in violation of UTMB’s policies and procedures or applicable law.

Mitigation may include, but is not limited to, the following:

    § Taking operational and procedural corrective measures to remedy violations.

    § Taking employment actions to re-train, reprimand, or discipline employees as necessary, up to and including termination.

    § Addressing problems with business associates once UTMB is aware of a breach of privacy.

    § Incorporating mitigation solutions into UTMB’s IHOP policies as appropriate.

    § Addressing and investigating faculty and student violations.

Violation of this policy may result in disciplinary action up to and including termination for employees; a termination of employment relationship in the case of contractors or consultants; or suspension or expulsion in the case of a student. Additionally, individuals may be subject to loss of access privileges and civil and/or criminal prosecution.

References

45 C.F.R. §164.530(f)

IHOP Policy 7.1.3, Student Conduct & Discipline

     

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