4.5.C HIPAA/Privacy: Other Requirements - Destruction of PHI/Shred Bin Policy

  • PURPOSE:

    The purpose of this policy is to inform all LHCC departments and employees of the proper procedures associated with the use of confidential paper shred bins in our offices.

    POLICY:

    LHCC employees must undertake appropriate administrative, technical, and physical safeguards, to the extent reasonably practical, to preclude PHI and confidential information from either intentional or unintentional use or disclosure, which would violate HIPAA regulations.

    Media with PHI and confidential information in hardcopy form, such as paper, must be protected against theft and unauthorized access. This includes all PHI and confidential informations in hardcopy form received, created, maintained, and transmitted by LHCC personnel. PHI and confidential information must be consistently protected and managed through its entire life cycle, from origin to destruction. Controls must be in place for hardcopy paper PHI and confidential information disposal and destruction.

    PROCEDURE:

    The paper shredding bins are for the secure destruction of PHI and confidential information. Once a document is placed in a shred bin, it is intended for secure destruction.

    1. Usage of Shred Bins
      1. The shred bins are to be used for the secure destruction of PHI and LHCC confidential information only.
      2. The shred bins are not to be used for non-confidential documents. The shred bins are not to be utilized for the destruction of personal (that is non LHCC) confidential information.
      3. Once any document is placed in a shred bin, the document is to be considered destroyed and NON-RETRIEVABLE. Therefore placing a document in the shred bin is the equivalent of using a shredder and the document is to be considered completely destroyed.
      4. The shred bins are not to be utilized for general recycling of non-PHI and non-confidential documents, journals, magazines, junk mail, cardboard, phone books, or any other type of non-confidential material. Other processes are available for recycling of non-confidential information.
    2. Location of Shred Bins at LHCC
      1. Shred bins are located throughout the LHCC organization in areas with PHI and confidential information.
    3. Addition or Removal of Shred Bins
      1. Shred bins will be located as conveniently as possible for all users.
      2. LHCC will evaluate any requests for additional bins or removal of bins.  These requests will be based on the following criteria:
        1. The actual need for additional shred bins
        2. Proximity of other shred bins
        3. Volume of confidential information for requested shred bin
        4. Type of material to be placed in the requested shred bin
    4. Servicing of Shred Bins
      1. LHCC will contract with an outside vendor to service the shred bins and destroy the contents. The vendor shall make regular rounds to ensure the bins are appropriately emptied.  
      2. When a shred bin is full prior to a regular servicing of the bin, the respective department must contact the vendor directly, or contact Beth Sockwell, to schedule additional servicing.
      3. If an issue or a problem with a shred bin or the vendor remains unresolved, the respective department shall contact the Compliance Officer.
    5. Unlocking of Shred Bins
      1. The Compliance Office, Office Managers or Purchasing Office should be the only offices that maintains the keys to unlock and open shred bins.
      2. ONCE ANY DOCUMENT IS PLACED IN A SHRED BIN, THE DOCUMENT IS TO BE CONSIDERED DESTROYED AND NON-RETRIEVABLE. Extenuating circumstances may necessitate unlocking and opening of a bin for retrieval of a document or item. Having to recreate a document mistakenly placed into the shred bin is NOT a reason to unlock and open a shred bin.
      3. If a shred bin required unlocking and opening, the requesting individual shall contact the Compliance Officer, Office Managers or Purchasing Office during regular business hours and schedule a time during regular business hours to have the shred bin unlocked and opened.
      4. When a shred bin is unlocked the requesting person and their manager shall be present during the time the bin is unlocked, opened, and relocked. NO ONE shall unlock any shred bin and leave it open.
      5. Prior to unlocking and opening a shred bin, the attached form must be completed detailing the reason for this action. This form must be completed in its entirety, to include reason, and signature.
      6. The Compliance Officer, Office Managers, or Purchasing Office shall directly observe the retrieval of all documents. The requesting person and their manager shall ensure confidentiality of all documents of the unlocked shred bin and that only relevant documents are removed.

    Revised 2/2014

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