hitech-breach-notification

name

hitech-breach-notification

description

Implements HITECH Act breach notification depth beyond baseline HIPAA—42 U.S.C. §17921–17923, ARRA Title XIII Subtitle D, OCR breach reporting portal workflows, 500+ individual media/HHS rules, business associate direct liability, encryption/unsecured PHI safe harbor analysis, and accounting of disclosures for breaches involving agent/LLM/MCP systems. Trigger when conducting HITECH-specific breach determinations, preparing OCR portal submissions, analyzing BA liability for LLM vendors, or auditing breach accounting and penalty exposure. Do not use for general incident containment (use breach-incident-response first), routine HIPAA Security Rule controls (use hipaa-technical-safeguards), or California CPRA consumer rights (use ccpa-cpra-privacy-rights).

HITECH Breach Notification

Overview

The Health Information Technology for Economic and Clinical Health (HITECH) Act (2009), codified at 42 U.S.C. §17921–17923 and implemented through HIPAA Omnibus Rule amendments, strengthened breach notification, extended direct liability to business associates (BAs), and increased civil monetary penalties.

HITECH element	Requirement	Primary reference
Breach notification	Individual, HHS, media (if >500 in state)	45 CFR §164.400–414; 42 U.S.C. §17921
Unsecured PHI	Breach applies to PHI not rendered unusable/unreadable/indecipherable	45 CFR §164.402; HHS encryption guidance
BA liability	BAs directly liable for Security, Privacy, Breach Notification	45 CFR §160.402(c)
OCR reporting	HHS breach portal; immediate if ≥500 individuals	HHS Breach Portal
Penalty tiers	Four tiers under HITECH (willful neglect, correction)	42 U.S.C. §1320d-5
Accounting of disclosures	Expanded accounting; breach may trigger disclosure log review	45 CFR §164.528

Relationship to breach-incident-response: Use that skill for containment, scope, and cross-framework incident orchestration. This skill adds HITECH-specific legal depth: unsecured PHI analysis, OCR portal mechanics, BA direct notification obligations, media triggers, and penalty-tier documentation.

AI/agent scenarios: LLM vendor without BAA receives ePHI prompts; MCP Postgres leak of session logs; failed redaction gate (agent.py) leading to model log retention; BA LLM subprocessors.

When to Use

Use this skill when:

• HITECH breach determination after initial incident classification (breach-incident-response Step 4 complete)
• Preparing HHS OCR breach portal submission (≥500 immediate; <500 annual aggregation)
• Analyzing whether PHI was secured (encryption per NIST SP 800-111 or equivalent) for safe harbor
• Business associate (LLM cloud, MCP host) must notify covered entity within 60 days of discovery (§164.410)
• Media notification required (>500 residents of a state or jurisdiction)
• Penalty exposure assessment and corrective action planning (willful neglect tiers)
• Accounting of disclosures update for breach-related unauthorized access
• Auditing HITECH compliance of agent pipelines post-incident

Do not use this skill when:

• Active containment still in progress (use breach-incident-response Steps 1–2 first)
• No PHI involved—pure PCI or SOC 2 incident without ePHI
• Preventive encryption design (use hipaa-technical-safeguards, pci-dss-encryption-key-management)
• State-only breach without HIPAA PHI (use us-state-privacy-laws)

Core Process

Execute after containment. Steps in order.

Step 1: Unsecured PHI determination

1. List PHI elements involved: identifiers, clinical data, dates, device IDs in agent logs.
2. Apply secured PHI test per HHS guidance:
   • Valid encryption per NIST SP 800-111 (or documented equivalent)?
   • Destruction of paper/electronic media per policy?
3. If PHI was encrypted at rest/in transit per guidance and key not compromised → may not be "unsecured" → breach may not apply.
4. Document analysis in templates/hitech-breach-workbook.yaml — do not assume encryption safe harbor without key compromise review.

Step 2: Four-factor risk assessment (§164.402(2))

If unsecured PHI involved, breach is presumed unless low probability documented:

Factor	Assessment questions
Nature and extent of PHI	Diagnosis, financial, SSN, full clinical notes in LLM prompt?
Unauthorized person	External attacker, rogue employee, non-BAA LLM vendor employee?
Was PHI acquired or viewed?	Log evidence, model training retention, MCP export?
Extent of mitigation	Revocation, deletion certificates, re-encryption?

Privacy officer signs determination: breach vs security incident (no breach).

Step 3: Individual notification (§164.404)

1. Without unreasonable delay, no later than 60 calendar days from discovery.
2. Content per §164.404(c):
   • Brief description of incident and dates
   • Types of PHI involved
   • Steps individuals should take
   • CE investigation and mitigation steps
   • Contact procedures (toll-free, email, website)
3. Substitute notice if insufficient contact data (>10 individuals): website 90 days, media, or email if consented.
4. For agent breaches: explain if LLM/MCP systems were involved without naming unnecessary clinical detail.

Step 4: HHS OCR notification (§164.408)

Affected count	Action	Timeline
≥500 in a state/jurisdiction	Submit via OCR Breach Portal	Without unreasonable delay, max 60 days; OCR expects prompt submission
<500	Log for annual submission	Within 60 days of calendar year end

1. Gather: CE/BA identity, incident dates, individuals affected, types of PHI, safeguards in place, brief description, mitigation.
2. Retain portal confirmation and submission ID in evidence manifest.
3. Cross-reference breach-incident-response timeline for discovery date (starts clock).

Step 5: Media notification (§164.406)

If >500 residents of a state or jurisdiction affected:

1. Notify prominent media outlets in affected areas without unreasonable delay (max 60 days).
2. Coordinate with legal/comms—message consistent with individual notice.
3. Document media list and publication dates.

Step 6: Business associate obligations (§164.410)

If CE uses BA (LLM vendor, MCP host, cloud agent platform):

1. BA must notify CE without unreasonable delay, no later than 60 days from discovery.
2. BA provides: identities of affected individuals if known, other information CE needs for notification.
3. If BA is agent skill operator's subprocessors chain, map contractual notice SLAs—contract must meet or beat 60 days.
4. CE remains responsible for individual/HHS/media notification unless delegated in BAA (uncommon).

Step 7: Penalty tier and corrective action (42 U.S.C. §1320d-5)

Document tier for management/legal (not legal advice):

Tier	Conduct	Planning use
1	Unknowing	Training gaps, undetected misconfig
2	Reasonable cause, not willful neglect	Process failure, delayed BA notification
3	Willful neglect, corrected	Known redaction bypass, uncorrected for period
4	Willful neglect, not corrected	Ignored OCR corrective action plan

1. Draft corrective action plan: fix redaction.py gate, MCP allowlists, BAA gaps.
2. Link to hipaa-baa-vendor-assessment for vendor remediation.

Step 8: Accounting of disclosures (§164.528)

1. Review whether breach constitutes disclosure requiring accounting update.
2. Update disclosure logs for affected individuals requesting accounting (6-year lookback).
3. Agent/MCP logs may be source of disclosure evidence—use hashed, access-controlled exports.

Step 9: Evidence and retention

1. Package: risk assessment, notification letters, portal submission, media proof, BA notices.
2. SHA-256 manifest per templates/audit-evidence-manifest.yaml.
3. Retain 6 years minimum (HIPAA documentation; state laws may differ).

Common Rationalizations

Excuse	Rebuttal
"Encrypted in transit to LLM—no breach."	Key compromise or vendor log retention of decrypted prompts voids safe harbor—document analysis.
"BA will handle all notifications."	CE retains primary notification duty unless explicit BAA delegation; verify contract language.
"<500 individuals—skip OCR until year-end."	Individual notice still required within 60 days; annual OCR log is separate obligation.
"We deleted LLM logs—no evidence of view."	Absence of logs does not negate breach presumption if unauthorized access was confirmed.
"HITECH is same as HIPAA breach skill."	HITECH adds BA direct liability, penalty tiers, and OCR portal mechanics requiring dedicated workbook.

Red Flags

• Discovery date undocumented (clock ambiguity)
• LLM vendor confirmed prompt retention without BAA
• ≥500 affected but no media notification plan
• BA notification received on day 59 with incomplete individual list
• Encryption claimed without NIST-aligned key management review
• OCR portal submission missing mitigation narrative

Verification

• Unsecured PHI analysis completed with encryption/key compromise review
• Four-factor risk assessment signed by privacy officer
• Individual notice drafted and 60-day deadline tracked
• HHS OCR portal path determined (immediate vs annual log)
• Media notification plan if >500 in state/jurisdiction
• BA notification chain documented with contractual SLAs
• Penalty tier and corrective action plan drafted for management
• Accounting of disclosures reviewed and updated if applicable
• Evidence manifest with SHA-256 hashes archived