What is a HIPAA Incident Response Plan?

Sarah Jones
HIPAA plan

It’s bad enough when a healthcare organization exposes patient protected health information (PHI). But, it can get worse if employees aren’t familiar with their organization’s HIPAA incident response plan. The plan outlines the policies and procedures in place to respond to and mitigate the effects of a data breach.  

In June 2023, a Kendall Park, New Jersey facility was fined $30,000 for improperly disclosing protected health information and failing to implement policies and procedures with respect to PHI. There are countless such cases every year even though it is relatively easy to create a HIPAA incident response plan.

Get tips to prepare for a HIPAA-related inspection from the Office of Civil Rights.

In this blog, we’ll discuss how HIPAA incident response requirements should be the anchor to a plan that serves as a defense mechanism for maintaining the trust and confidentiality that form the foundation of the patient-care provider relationship.

What is a HIPAA Incident?

The Health Insurance Portability and Accountability Act (HIPAA) establishes national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.

According to the Department of Health and Human Services’ Office of Civil Rights (OCR), a HIPAA incident involves any unauthorized access, use, disclosure, or breach of unsecured protected health information (PHI). Unsecured PHI refers to information that is not rendered unusable, unreadable, or indecipherable to unauthorized individuals through technology or methodology specified by the Secretary of HHS.

In simpler terms, if someone who doesn’t have permission to see or use patient information gains access to it in a way that compromises the security or privacy of that information, a HIPAA incident has occurred. That’s why healthcare organizations should enact protective measures and response strategies to promptly address potential vulnerabilities.

HIPAA Incident Response Requirements

The HIPAA Privacy and Security Rules mandate that covered entities and their business associates, which include a broad range of healthcare providers, health plans, and healthcare clearinghouses, implement policies and procedures to respond to HIPAA incidents. The cornerstone of these requirements is the incident response plan.

A HIPAA incident response plan is a set of policies and procedures that organizations should have in place to help them respond to and mitigate the effects of a data breach. It should include the following key actions:

  • Designate a security officer: This person will be responsible for overseeing the organization’s HIPAA compliance efforts and coordinating the response to any security incidents.
  • Develop and implement policies and procedures: These policies and procedures should address how the organization will respond to a data breach, including how to notify affected individuals, contain the breach, and mitigate any damage.
  • Regularly test the plan: The organization should regularly test its incident response plan to ensure that it is effective and that all employees are familiar with their roles and responsibilities.
  • Document all security incidents: The organization should document all security incidents, including the date and time of the incident, the nature of the incident, and the steps taken to respond to the incident.
  • Provide security awareness training to all employees: All employees should receive regular security awareness training to help them understand their role in protecting the organization’s data.

Breach Notification Requirements

HIPAA requires covered entities to report certain types of incidents to the affected individuals, the HHS, and, in cases of breaches affecting more than 500 individuals, to the media. These notifications must occur without unreasonable delay and in no case later than 60 days following the discovery of a breach. The notice must provide a clear description of what happened, the types of PHI involved, the steps individuals should take in response, and what the covered entity is doing to investigate, mitigate harm, and protect against future breaches.


Download a free and ready-to-use HIPAA Breach Notification Policy.

The penalties for failing to comply with HIPAA incident response requirements can be severe, ranging from monetary fines to criminal charges, depending on the nature of the violation and the level of negligence involved. Fines can reach up to $1.5 million per violation category per year, and criminal charges can result in significant fines and imprisonment.

Simplify HIPAA Compliance with MedTrainer

Compliance software, like MedTrainer, plays a crucial role in supporting HIPAA compliance efforts for healthcare facilities. These systems enable organizations to:

  • Streamline the process of policy creation, approval, and distribution.
  • Provide version control and document history for audit purposes.
  • Automate policy acknowledgments and employee training tracking.
  • Customize reporting for audits and surveys by maintaining a comprehensive record of policy adherence and employee training.

Explore more about MedTrainer’s all-in-one compliance platform specifically designed for healthcare professionals.


See how MedTrainer can streamline your compliance.