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Title: Facility Security Plan Policy: SEC 10.02
Category: HIPAA Compliance Authority: 45 CFR § 164.310 (a) (1)
HIPAA Section:
Standard: Facility Access Controls Responsibility: Health Care Components
Effective Date: 04/20/2005 Page 1 of 1
Approved by: OSU Legal Counsel Revised:

Purpose

Identify process to secure facilities housing EPHI

Policy

Employees will take necessary steps to protect and secure protected health information in their areas.

CHS Procedure

Refer to CIC-1-14.01

UHS and SWC Procedure

The Sr. Administrative Associate will maintain records sufficient to document key distribution among UHS/SWC staff. To the extent possible, key distribution is kept to a minimum. Only authorized staff can obtain a building master and its use shall be documented. Any loss of a building master will be reported to the Sr. Administrative Associate.

Each employee shall assume responsibility for assisting in maintaining a secure work place. This includes control of access by non-staff to patient care areas and work areas. Any suspicious behavior by non-staff should be confronted by UHS/SWC staff or supervisor. If there is perceived to be any potential risk to staff or patients, OSU Police should be contacted immediately.

To minimize unauthorized access to patient confidential information, staff should refrain to the extent possible, accessing areas to which they are not assigned. As well, staff should politely challenge other staff who may be present in non-assigned work areas.

Staff should, to the greatest extent possible, minimize or prevent non-staff from entering work areas. This includes friends, family, students and other OSU staff. It is recognized that this is not always possible and in such circumstances the employee should take steps to cover work, log off computers, and in any other way possible, prevent unauthorized individuals from observing or having visual or auditory contact with protected health information of any kind.

It is recognized that from time to time it will be necessary for maintenance and repair personnel to be in areas in which confidential information is present. All routine repairs and maintenance will be done during business hours with staff available to oversee and ensure that inappropriate access and actions are not taken. In the case of emergencies, UHS/SWC will cooperate with OSU Physical Plant and other university authorized staff to allow access to the areas needing repair while insuring that inappropriate behaviors are prevented.

  1. 1. UHS/SWC will maintain a process to assign building keys to specified staff.

  2. UHS/SWC will maintain a process to assign room keys to specified staff.

 

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