14.HCS.IM.2 ( HCS)
The organization maintains and protects the security and integrity of health information.
Rationale
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• IM.2 1. The program has a written policy to address privacy, confidentiality, and security of information.
Note: Health information is protected under the Health Information Portability Accountability Act (HIPAA).
2. The program defines access limitations to information for individuals and/or positions.
3. The program safeguards records and information against loss, destruction, tampering, and unauthorized access or use.
4. The program defines the process to follow when confidentiality or security of information is breached.
5. The program implements its privacy, confidentiality, and security of information policy.
6. The program retrieves data without compromising security and confidentiality.
7. The program communicates its privacy, confidentiality, and security of information policy to staff and the patient.
8. The program informs staff and patients about its uses and disclosure of protected health information and obtains consent for release of information when required.
9. Patients are made aware of how data and information related to them will be used by the program.
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