BHA 4006 CU Compliance Program Implementation & Ethical Decision Making Essay

User Generated

lebqev02

Health Medical

BHA 4006

Capella University

BHA

Description

Prepare a workplace brief (8-10 double-spaced pages) to address a privacy breach that occurred in a health care organization. Include the consequences of failure to act and evidence-based recommendations for addressing the breach.

Introduction

Health care is one of the most heavily regulated major industries in the United States. Leaders are challenged to stay current and to comply with federal, state, and local laws and their associated regulations. Health care organizations are also responsible to meet industry standards. In some cases, payers equate meeting industry standards with achieving and maintaining accreditation. In fact, many payers consider accreditation a minimum condition of participation. In addition, individual licensure and certification requirements establish basic expectations for health care leaders' professional conduct.

In summary, health care leaders are responsible to:

  1. Meet ethical personal, professional conduct, certification and licensure expectations.
  2. Comply with local, state and federal health care and human resources laws.
  3. Provide evidence of compliance with existing regulations and scan the field for emerging regulations.
  4. Identify and meet appropriate accrediting body standards (Example: Joint Commission’s National Patient Safety Goal standards.)

As an individual’s health care leadership career advances, so does the corresponding level of accountability. Not knowing the laws or regulations is not an excuse for not complying with them.

This assessment allows you to demonstrate your knowledge of and skills relating to compliance concepts, governmental and regulatory agencies which oversee health care service delivery, billing, and general operations. You will also have the opportunity to apply the components necessary to initiate and maintain an effective compliance program. Finally, you will consider relevant human resources laws which may pertain to your compliance recommendations.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

  • Competency 1: Analyze health care laws and regulations from a local, state, and federal level.
    • Summarize the relevant health care compliance concepts that apply to a HIPAA privacy breach.
  • Competency 3: Assess the importance of continuous readiness in the health care organization.
    • Apply the seven essential elements of an effective compliance program to a HIPAA privacy breach.
    • Recommend evidence-based actions to address a HIPAA privacy breach.
    • Describe a health care, industry-approved, ethical decision-making framework.
  • Competency 4: Explain how governing body and regulatory agency standards exercise oversight authority within a health care organizational setting.
    • Provide a synopsis of the consequences to individual leaders and other internal stakeholders of not addressing a HIPAA privacy breach.
  • Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
    • Write a clear, concise, well-organized, and generally error-free workplace brief addressing a HIPAA privacy breach that is reflective of professional communication in the health care field.

Instructions

In this assessment, you are assuming the role of an early careerist in risk management and quality improvement at one of Vila Health's community-based hospitals. Vila Health is a medium-sized system of health operating facilities in Minnesota and Wisconsin. You are working on a team-based initiative under the supervision of the Vila Health Chief Compliance Officer. Your role is to assist in addressing a specific compliance risk regarding a breach of privacy and potential HIPAA violation. A Vila Health employee has disclosed—without prior written authorization—a patient's protected personal health information.

Here is the information the team has collected about the privacy breach and potential HIPAA violation to date. A Vila Health supervisor instructed an employee to obtain pre-authorization for an upcoming surgical procedure for a patient. The Vila Health employee submitted confidential, protected health care information about the patient to the insurance company. The Member Services Representative at the insurance company contacted the Vila Health supervisor. The insurance company representative indicated that further discussion of the matter without prior written consent from the patient is prohibited.

As part of the team exploring the privacy breach, you will prepare a workplace brief with authoritative, evidence-based references to support your work.

Preparation

You are already familiar with HIPAA but may want to conduct independent research to enhance your knowledge. Consult this resource for additional guidance on how to conduct research using credible sources: Health Care Administration Undergraduate Library Research Guide.

Instructions

This is a workplace brief rather than an academic paper. Download the Compliance Program Implementation and Ethical Decision-Making Template [DOCX]. Be sure to address all of the following in your brief:

Background

Include a short paragraph of no more than five or six sentences describing the known details about the privacy breach and HIPAA violation.

Privacy Breach—HIPAA Violation

Summarize the relevant health care compliance concepts that apply to this privacy breach and HIPAA violation. Be sure to consider the following:

  • Federal, state, and local laws and associated regulations.
  • Disclosure.
  • Human resource concepts and law(s).
  • Industry and accrediting body standards.
Seven Essential Elements of an Effective Compliance Program

Apply to this HIPAA breach the seven essential components of an effective health care compliance program, as determined within the Federal Register.

Privacy Breach Consequences

Provide a synopsis of the consequences for an individual leader and for other internal health care organization stakeholders for not taking immediate actions to address a privacy breach. At a minimum, be sure to consider all of the following in your synopsis:

  • Patient safety.
  • Financial losses.
  • Individual and organizational violations of the law.
Evidence-Based Recommendations

Construct evidence-based recommendations to resolve the HIPAA-related privacy breach. You may also want to include relevant information related to:

  • Human resource laws.
  • Professional codes of ethical conduct and standards.
  • Previous case precedents.
  • Current alleged health care legal violations.

For help in identifying appropriate evidence-based recommendations, you may want to visit some of the authoritative sources, such as the DOJ/OIG, CMS/HHS, et cetera, listed under the suggested resources for this assessment.

Ethical Decision-Making Framework for Health Care Leaders

Describe an ethical decision making framework as one of your concluding recommendations. Tip: You may want to use the ACHE’s ethical decision-making framework:

Conclusion

Write a paragraph that summarizes the following:

  • Key concepts.
  • Importance of compliance.
  • Best practices to monitor for future quality improvements.
  • Short list of resources.
  • Note: Be sure to include all appropriate citations.

Additional Requirements

  • Written communication: Use the Compliance Program Implementation and Ethical Decision-Making Template linked above. Your workplace brief needs to be clear, concise, well-organized, and generally free of errors in grammar, punctuation, and spelling. The title page, citations, and references need to be in current APA format.
  • Length: Approximately 8–10 typed, double-spaced content pages in Times New Roman, 12-point font, including the reference page.
  • Title page: Develop a descriptive title of approximately 5–15 words. It should stir interest, yet maintain professional decorum. Ensure that your title page conforms to current APA format.
  • References: Include a minimum of six current, authoritative citations and references in current APA format.
  • Scoring guide: Please review the scoring guide for this assessment so that you understand how your faculty member will evaluate your work.

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Explanation & Answer

Hi, kindly find attached

Compliance Program Implementation and Ethical Decision-Making
Student’s Name

Institution

Date

1

Background

The HIPAA breach notification rule, 45 CFR SS 164.400-414, requires HIPAA covered bodies and their business associates to provide
notification following a breach of unsecured protected health information. Such breach notification provisions implemented and
enforced by the Federal Trade Commission apply to vendors of personal health records and third-party service providers, according to
section 13407 of the HITECH Act. Therefore, a breach is an impermissible use or disclosure under the Privacy Rule that compromises
the protected health information's security or privacy. An impermissible use or disclosure of protected health information is assumed to
be a breach unless the covered entity or business associate, as applicable, demonstrates a low probability that the protected health
information has been compromised based on a risk assessment. Covered entities and business associates, where applicable, choose to
deliver the necessary breach notifications following an impermissible use or exposure without execution of a risk assessment to define
the probability that the protected health information has been compromised (Edemekong, Annamaraju, & Haydel, 2020).

Some exceptions are associated with the definition of breach. With the first one applying to the unintentional acquisition, access, or use
of protected health information by a workforce member or someone is acting under the authority of a covered entity or business associate,
if the access and use were done in good faith and within the range of authority. The other exception applies to the inadvertent disclosure
of protected health information by someone who is allowed to access protected health information at a covered entity or business
associate to someone else who is also allowed to access the protected health information. The last exception applies if the covered entity

2

or business associate has a good faith belief that the unapproved person to whom the impermissible exposure was made would not have
been capable of retaining the information (Edemekong, Annamaraju, & Haydel, 2020).

Problem Summary: Privacy Breach—HIPAA Violation

Briefly Explain the Law, Regulation, Standard,

Briefly Explain How the Law, Regulation,

et cetera*

Standard, et cetera Applies to the Privacy
Breach/HIPAA Violation

Applicable Law(s)

HIPAA are rules that cover the allowable uses and Healthcare providers are required to comply to the
disclosures of protected health information secure HIPAA rules. The rules provide guidelines to the
and data security.

healthcare providers which govern the sharing and
exposure of protected health information. It also
provides consequences in case of privacy breach.

Applicable
Regulation(s)

Specific HIPAA

regulations

assures

one’s

health It regulates a balance that permits essential use of

information is well protected hence allowing the information while protecting the privacy of patients.
flow of health information needed to provide high With the diverse health care market, the rule is flexible

3

Briefly Explain the Law, Regulation, Standard,

Briefly Explain How the Law, Regulation,

et cetera*

Standard, et cetera Applies to the Privacy
Breach/HIPAA Violation

quality health care and to protect the public’s health and comprehensive to cover the variety of uses and
and wellbeing.

disclosures that require to be addressed.

The privacy rule standards address the use and It sets the standards for person’s privacy rights to

Disclosure

disclosure of patient’s health information.

understand and control how their health information is
used.

Applicable

Human The laws are used in work places to protect the They regulate how employee’s protected healthcare

Resource Law(s)

health

and

medical

records

of

employees information maintained by healthcare plan can be

participating in an employer sponsored health care shared with employers.
plan.
Applicable
Accrediting
Standards

Industry The privacy and security standards apply to It provides standards for health information exchanges,
Body business associates and also to healthcare which enable the electronic transfer of healthcare
organizations covered by HIPAA regulations.

information across organizations.

4

(Rouse, 2017).

Seven Essential Elements of an Effective Compliance Program

Number

Element of an Effective Compliance Program

How Does This Element Apply to the Privacy Breach/HIPAA
Violation?

(Federal Register)*
1.

Implementing written policies, procedures, and It provides clear guidelines and rules that assist the employees in
standards of conduct

carrying out their job functions in a way that it ensures compliance
with the federal health care program requirements and advances the
mission and objective of the hospital itself.

2.

Designating a compliance officer and compliance The compliance officer is obligated with operating and monitoring
committee

the compliance program as well as taking the specified procedures
in case of health information breach. The committee includes
members of key functions in the facility that can support and advise
the compliance officer.

5

Number

Element of an Effective Compliance Program

How Does This Element Apply to the Privacy Breach/HIPAA
Violation?

(Federal Register)*
3.

Conducting effective training and education

All the employees and the board members are trained on fraud and
abuse of the law as well as the training program and also the
consequences that come along with breaching the privacy rules.

4.

Developing effective lines of communication

In case of any breach of the health information, the employees
should feel comfortable reporting internally, and organizations
should have several reporting avenues like the compliance officer
and anonymous hotline. The reports should be taken seriously and
follow ups conducted.

5.

Conducting internal monitoring and auditing

It will involve an ongoing process of evaluation to discourage
unwanted access of information and ensure effectiveness of
education and corrective action. It will also monitor compliance
with privacy, and deliver a risk assessment of possible privacy
concerns.

6

Number

Element of an Effective Compliance Program

How Does This Element Apply to the Privacy Breach/HIPAA
Violation?

(Federal Register)*
6.

Enforcing

standards

through

disciplinary guidelines

well-publicized The compliance ought to work with human resources and legal to
ensure the standards and consequences for HIPAA violations are
consistently enforced.

7.

Responding promptly to detected offenses and Ensures timely and effective remedial action for any privacy
undertaking corrective actions

offense failure to which can generate further exposure of the
organization.

(Andreisová, 2016).

7

Privacy Breach Consequences

Covered Entity
Individual

Legal Penalty(ies)*

Additional Consequences

Leader For no knowledge of violation – Minimum fine of Imprisonment up to one year for reasonable cause of

Within Health Care $100 to a maximum $50,000 per violation with a violation
Organization

maximum of $25,000 per year.
Up to five years in jail for obtaining PHI under false
For reasonable cause the fine is $1,000 to $50,000 pretenses
per violation with maximum of $100,000 per year.
Imprisonment of up to 10 years for Obtaining PHI for
In case of willful neglect of the HIPAA rules with personal gain
the violation corrected within 30 days of
discovery, - $10,000 to $50,000 per violation with
a maximum of $250,000 per year.

Willful neglect of HIPAA rules without efforts to
correct the violation within 30 days of discovery -

8

Covered Entity

Legal Penalty(ies)*

Additional Consequences

$50,000 per violation with a maximum of $1.5
million per year.

Other Internal Health The directors of the organization stakeholders or Imprisonment up to one year for reasonable cause of
Care

Organization the individual stake holders will be responsible of violation

Stakeholders

the HIPAA violations.
Up to five years in jail for obtaining PHI under false
For no knowledge of violation – Minimum fine of pretenses
$100 to a maximum $50,000 per violation with a
Imprisonment of up to 10 years for Obtaining PHI for
maximum of $25,000 for repeat violations.
personal gain
For reasonable cause the fine is $1,000 to $50,000
per violation with maximum of $100,000 for
repeat violations.

9

Covered Entity

Legal Penalty(ies)*

Additional Consequences

In case of willful neglect of the HIPAA rules with
the violation corrected within 30 days of
discovery, - $10,000 to $50,000 per violation with
a maximum of $250,000 for repeat violations.

Willful neglect of HIPAA rules without efforts to
correct the violation within 30 days of discovery $50,000 per violation with a maximum of $1.5
million per year.
HealthCare

The director of the organization will be Imprisonment up to one year for reasonable cause of

Organization

responsible for the violations since the CE is not violation
an individual.
Up to five years in jail for obtaining PHI under false
pretenses

10

Covered Entity

Legal Penalty(ies)*

Additional Consequences

For no knowledge of violation – Minimum fine of Imprisonment of up to 10 years for Obtaining PHI for
$100 to a maximum $50,000 per violation with a personal gain
maximum of $25,000 for repeat violations.
Can lead to financial losses
For reasonable cause the fine is $1,000 to $50,000
It also weaknesses the safety of the patients
per violation with maximum of $100,000 for
repeat violations.

In case of willful neglect of the HIPAA rules with
the violation corrected within 30 days of
discovery, - $10,000 to $50,000 per violation with
a maximum of $250,000 for repeat violations.

Willful neglect of HIPAA rules without efforts to
correct the violation within 30 days of discovery -

11

Covered Entity

Legal Penalty(ies)*

Additional Consequences

$50,000 per violation with a maximum of $1.5
million per year.

(Parks, & Lowry, 2017)

Evidence-Based Recommendations

Number Evidence-Based Recommendation
1.

Systems

that

contain

protected

Additional Insights/Salient Points

Source(s)*

health The health care data servers are the leading target of Khan,

S.,

&

information need to be protected from possible the hackers because of monetary value. It is therefore Hoque, A. (2016).
cyber-crimes.

important for the healthcare organizations to invest in Digital

health

strategies to mitigate the risk of attacks and minimize data:

A

the chances of compromising privacy information of comprehensive
a patient.

review of privacy

12

Number Evidence-Based Recommendation
2.

Additional Insights/Salient Points

Source(s)*

In order to facilitate knowledge discovery By replacing the personal identifiable attributes with and security risks
process

of

the

healthcare

information, unique code, it will not be possible for someone to and

some

sufficient record-linkage data has to be kept in identify information attributed to specific individual recommendations.
medical

3.

record

by

replacing

personal for the purpose of unwanted use or illegal theft.

Computer Science

identifiable attributes with unique code using

Journal

suitable computer cryptographic technique.

Moldova,

Proper security measures need to be taken and

of
71(2),

273-292.

tested before connecting the organization
health data to the internet.
4.

It is important to educate healthcare staff about The healthcare staffs should attend classes that help Hoffman, S. A. E.
the HIPAA and PHI rules and guidelines.

them understand the HIPAA rules, policies and the (2020).
procedures. The security awareness training will Cybersecurity
equip the healthcare employees with the requisite Threats

in

13

Number Evidence-Based Recommendation

Additional Insights/Salient Points

Source(s)*

knowledge necessary for making informed decisions Healthcare
about the patient data.

5.

Organizations.

Organizations need to implement multi-factor Organizations should restrict access to data and
authentication that require users to validate Applications

Access

restrictions

oblige

user

World

Libraries,

24(1).

their identity through various validation authentication. This will ensure that only authorized
methods.

users have access to protected data.

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

1.

Recognize the background – the circumstances At this stage I will identify all the relevant factors contributing to the
leading to the ethics conflicts.

privacy breach. The healthcare employee and the affected patient will

14

Number Ethical Decision-Making Step*

Apply the Ethical Decision-Making Step to the Privacy
Breach/HIPAA Violation
be given the chance to express their issues. In the case that the two
parties reach agreement on the matter we can diminish the ethical
conflict. If the conflict continues we will move to the next step.

2.

Identify the specific ethical question that need We will specifically articulate the ethics conflict after determining all
clarification

the facts. The ethical question will now focus on identifying and
agreeing on the competing issue. The ethical question will be
identified and reviewed in a way that consensus is reached among the
healthcare employee and patient whom data was breached.

3.

Consider the related ethical principles and Determination of whether any particular organizational policies or
organizational values

legal perspectives relate to the ethics question. At this step it will be
ensured that clear identification of the specific competing values is
achieved.

15

Number Ethical Decision-Making Step*

Apply the Ethical Decision-Making Step to the Privacy
Breach/HIPAA Violation

4.

Determining the options for response

All the potential options for responding to the ethical question will be
realized. We are going to review the ethical justification ...


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