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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?
1.
2.
3.
4.
5.
6.
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)*
1.
2.
3.
4.
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
1.
2.
3.
4.
5.
6.

*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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