Compliance Program Implementation and Ethical Decision-Making Template
Background
Include a short paragraph of no more than five or six sentences describing the known details about the privacy breach/HIPAA violation.
Problem Summary: Privacy Breach—HIPAA Violation
Briefly Explain the Law, Regulation, Standard, et cetera*
Briefly Explain How the Law, Regulation, Standard, et cetera Applies to the Privacy Breach/HIPAA Violation
Applicable Law(s)
Applicable Specific Regulation(s)
Disclosure
Applicable Human Resource Law(s)
Applicable Industry Accrediting Body Standards
*Include citations from authoritative government, accrediting body, and peer-reviewed industry sources.
Add additional salient points if needed:
Seven Essential Elements of an Effective Compliance Program
Number
Element of an Effective Compliance Program
(Federal Register)*
How Does This Element Apply to the Privacy Breach/HIPAA Violation?
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7.
*Include source citation(s).
Privacy Breach Consequences
Covered Entity
Legal Penalty(ies)*
Additional Consequences
Individual Leader Within Health Care Organization
Other Internal Health Care Organization Stakeholders
Health Care Organization
*Include citation(s) from authoritative government and related sources.
Evidence-Based Recommendations
Number
Evidence-Based Recommendation
Additional Insights/Salient Points
Source(s)*
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5.
*Include citation(s) for human resource laws, professional codes of ethical conduct/standards, previous case precedents, and current alleged health care legal violations. Example: DOJ/OIG, CMS/HHS, et cetera websites.
https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/examples/all-cases/index.html?language=es
Ethical Decision-Making Framework for Health Care Leaders
Number
Ethical Decision-Making Step*
Apply the Ethical Decision-Making Step to the Privacy Breach/HIPAA Violation
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*Include citation. Example: https://ache.org/abt_ache/EthicsToolkit/JA15_ethic_reprint.pdf
Conclusion
Include a short paragraph that summarizes: key concepts, importance of compliance, best practices to monitor for future quality improvements, and a short list of resources. Be sure to include all appropriate citations.
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