Mitigation Policy

Mitigation After Improper Protected Health Information Use Or Disclosure

SCOPE:

All Louisiana State University (LSU) System health care facilities and providers including, but not limited to hospitals, physician practices, clinics, schools, etc. on the LSU Health Sciences Center New Orleans Academic Campus.

Nota Bene: All LSU System health care facilities and providers including, but not limited to hospitals, physician clinics, schools, etc. on the LSU Health Sciences Center New Orleans Academic Campus, are referred to in this policy as LSUHSC-NO.

PURPOSE:

To provide guidance to the LSUHSC-NO health care facilities and providers to the extent practicable, to mitigate (lessen or alleviate) any harmful effect that becomes known to them as a result of an improper use or disclosure of PHI.

POLICY:

LSUHSC-NO has a duty to ensure the proper use and/or disclosure of PHI. To the extent practicable, the LSU facility will mitigate (lessen or alleviate) any harmful effect that becomes known to LSUHSC-NO as a result of a use or disclosure of PHI in violation of LSUHSC-NO’s policies and procedures or applicable law.

PROCEDURE:

The duty to mitigate includes, but is not limited to the following:

• Taking operational and procedural corrective measures to remedy violations.
   
• Taking employment actions, reprimand, or discipline employees as necessary, up to and including termination.
   
• Addressing problems with business associates once LSU is aware of a breach of privacy.
   
• Incorporating mitigation solution into the LSUHSC-NO facility’s operational policies as appropriate.
   
• Addressing and investigating LSUHSC-NO facility workforce violations.

ENFORCEMENT:

Individuals who violate this policy will be subject to the disciplinary process for LSUHSC-NO.

REFERENCES:  

45 C.F.R. 164.530(f), LSUHSC-N.O. Disciplinary policy