Compliance Program Implementation and Ethical Decision-Making Template

Background

There are several practices that health care professionals may overlook. At the same time, in the real sense, they are an actual violation of the Health Insurance Portability and Affordability Act (HIPAA) and breaches in patient privacy (Puri, Kaur, & Sachdeva, 2020). Among the issues includes sending to collection firms actual patient bills. This issue ensured the suspension of the practice license belonging to Dr. Victor Young, a psychotherapist and the managing director at Young Psychotherapists. Case files revealed that doctor young’s employees engaged in a regular forwarding of past-due bills of patients to a collections firm. Since such bills contained highly protected patient information such as CPT codes that could reveal the diagnoses of the various patients, the act was a gross violation of HIPAA provisions and a significant breach to patient privacy. According to HIPAA provisions, providers should exclude all patient information while submitting to collections firms the necessary patient information (Puri, Kaur, & Sachdeva, 2020). As such, instead of including protected patient information such as CPT codes in the bills, the employees ought to have emitted all patient data while sending the bills to the collection firm.

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)	The first law that applies to the privacy issue includes the 1996 Health Insurance Portability and Affordability Act and Privacy Security and Breach Rule. The Privacy Rule not only offers the patient the right with respect to health information but also limits the use and sharing of patient information with other parties (HHS, 2020). As such, HIPAA offers that providers should exclude all patient information while submitting the necessary patient information to any third party who is not concerned with the management of the patient’s condition. Another applicable law is California’s Confidentiality on Medical Information Act (CIMIA), which prohibits providers, contractors, or health care service plan from medical information in regards to the patient’s information without consent.	The Privacy Rule applies to the violation in that Dr. Young’s employees engaged in a regular forwarding of past-due bills of patients to a collection firm contrary to the provisions of this law that offers the patient the right in respect to health information besides limiting the use and sharing of patient information with other parties. Moreover, HIPAA provides that providers should exclude all patient information while submitting the necessary patient information to any third party who is not concerned with the management of the patient’s condition, and Young Psychotherapists were in a complete violation of such provisions (HHS, 2020). Similarly, the employees went ahead to disclose private information to the collections firm hence violating CIMIA’s rule that prohibits a provider from medical information in regards to the patient’s information without consent.
Applicable Specific Regulation(s)	The Department of Human and Health Services (HHS) Privacy Act Regulation is also applicable to the breach of privacy. This regulation is a provision to the procedures as well as the policies under which providers can maintain health records.	The HHS Privacy Act Regulation applies to the privacy breach in that when Dr. Young’s employees engaged in a regular forwarding of past-due bills of patients to a collection firm, it participated in a violation of the policies that the regulation provides of maintaining health records. According to the provisions of the policy, providers should oversee any possible way through which protected health information could leak to an unauthorized third party such as the collections firm.
Disclosure	The 2003 National Health Act makes disclosure of patient information an offense without their consent, whether intentionally or unintentionally (Rickert, 2020).	This disclosure policy applies to the HIPAA violation in that Dr. Young’s employees engaged in a regular forwarding of past-due bills of patients to a collection firm; hence unintentionally disclosed vital patient information to unauthorized third parties.
Applicable Human Resource Law(s)	Federal Acquisition Regulations and Laws require employers to train their employees regularly and compliance and ethical awareness to avoid making mistakes that could breach client confidentiality (Rickert, 2020).	For Dr. Young’s employees to engage in a regular forwarding of past-due bills of patients to a collection firm, it would mean that the company never participated in periodic training of the employees to make them wary of the fact that they needed to exclude all patient information while submitting the necessary data to any third party who is not concerned with the management of the patient’s condition.
Applicable Industry Accrediting Body Standards	The Joint Commission National Patient Safety Goals (NPSGs) are standards that aim at keeping patient safety through a wide variety of measures, including ensuring that providers ensure privacy issues (Rickert, 2020).	By ensuring that providers observe patient privacy issues to ensure safety, the privacy breach runs against the NPSGs as a standard since Dr. Young’s employees to engage in a regular forwarding of past-due bills of patients to a collection firm.

Department of Human and Health Services. (2020). The Privacy Act. Retrieved from https://www.hhs.gov/foia/privacy/index.html

Rickert, J. (2020). On Patient Safety: The Lure of Artificial Intelligence—Are We Jeopardizing Our Patients’ Privacy? A Publication of the Association of Bone and Joint Surgeons®| CORR®, 478(4), 712-714.

Seven Essential Elements of an Effective Compliance Program

Number	The element of an Effective Compliance Program (Federal Register)*	How Does This Element Apply to the Privacy Breach/HIPAA Violation?
1.	Implementation of written procedures, programs, policies, and standards of conduct.	Because Dr. Young’s employees engaged in regular forwarding of past-due bills of patients to a collection firm, it is to the implication that the provider did not participate in the adequate implementation of written procedures, programs, policies, and standards of conduct (Koskimies, Koskenniemi, & Leino-Kilpi, 2020).
2.	Designation of a compliance officer as well as a compliance committee.	By designing compliance officers as well as the compliance committee, it would have been possible to detect the problem of forwarding of past-due bills of patients to a collection firm early enough to avoid leakage of protected patient information to a third party (Koskimies, Koskenniemi, & Leino-Kilpi, 2020).
3.	Conducting effective education as well as training.	If the provider could have engaged in practical training as well as the education of the employees, the staff would not have made the gross mistake of forwarding of past-due bills of patients to a collection firm to violate HIPAA provisions (Koskimies, Koskenniemi, & Leino-Kilpi, 2020).
4.	Conducting internal auditing as well as monitoring.	Similarly, if the provider would have engaged in internal auditing and monitoring, it would have discovered the underlying problem before the employees forward past-due bills of patients to a collection firm to breach patient privacy. (Koskimies, Koskenniemi, & Leino-Kilpi, 2020).
5.	Enforcement of standards via well-published disciplinary guidelines.	If the provider had enforced standards via well-published disciplinary guidelines, the employees would have known better than to forward past-due bills of patients to a collection firm hence breaching patient privacy.
6.	Prompt response to detected offenses as well as undertaking corrective measures.	If the provider engages in prompt response to detected offenses as well as undertaking corrective measures, it would have discovered and corrected the underlying problem before the employees forward past-due bills of patients to a collection firm to breach patient privacy (Koskimies, Koskenniemi, & Leino-Kilpi, 2020).
7.	Development of active communication lines.	If the provider could have developed active lines of communication, it could have been possible to prevent the breach in patient privacy as conversation opens up the flows in a system (Koskimies, Koskenniemi, & Leino-Kilpi, 2020).

Koskimies, E. M., Koskenniemi, J., & Leino-Kilpi, H. (2020). Patient’s informational privacy in prehospital emergency care: Paramedics’ perspective. Nursing Ethics, 27(1), 53-66.

Privacy Breach Consequences

Covered Entity	Legal Penalty(ies)*	Additional Consequences
Individual Leader Within Health Care Organization	Suspension of individual practice license and possible imprisonment (Arain, Tarraf, & Ahmad, 2019).	Loss of job due to termination as a result of incompetency. Salary cuts cover for the damages to the organization as a result of the lawsuits due to the breach in patient privacy.
Other Internal Health Care Organization Stakeholders	Employees who are engaged directly in the breach of patient privacy could also suffer suspension of personal practice licenses and possible imprisonment (Arain, Tarraf, & Ahmad, 2019).	Loss of job due to termination as a result of incompetency. Salary cuts cover for the damages to the organization as a result of the lawsuits due to the breach in patient privacy.
Health Care Organization	Suspension of organizational practice license (Arain, Tarraf, & Ahmad, 2019).	Decline in customer confidentiality due to breach in private information. A decline in revenue generated by the health care organization due to a decrease in consumer volume.

Arain, M. A., Tarraf, R., & Ahmad, A. (2019). Assessing staff awareness and effectiveness of educational training on IT security and privacy in a large healthcare organization. Journal of multidisciplinary healthcare, 12, 73.

Evidence-Based Recommendations

Number	Evidence-Based Recommendation	Additional Insights/Salient Points	Source(s)*
1.	Conducting a risk assessment.	Conducting a risk assessment of the IT system is the first stage of the requirements for meaningful use of incentive programs as a provision by the Centers for Medicaid and Medicare Services (CMS, 2018).	Centers for Medicare and Medicaid Services. (2018). HIPAA basics for providers: privacy, security, and breach notification rules. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/hipaaprivacyandsecuritytextonly.pdf
2.	Providing continuous education and learning opportunities to the employees on HIPAA provisions.	To ensure that the employees stay up to date with the HIPAA rules and regulations, education and reeducation would be of considerable significance to prevent a breach in patient privacy (CMS, 2018).	Centers for Medicare and Medicaid Services. (2018). HIPAA basics for providers: privacy, security, and breach notification rules. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/hipaaprivacyandsecuritytextonly.pdf
3.	Engaging in regular monitoring of records and devices.	Monitoring records on protected patient information and the devices used to store and make such records is of considerable significance in ensuring data privacy (CMS, 2018).	Centers for Medicare and Medicaid Services. (2018). HIPAA basics for providers: privacy, security, and breach notification rules. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/hipaaprivacyandsecuritytextonly.pdf
4.	Encryption of data as well as hardware.	Encryption of data and software plays an essential role in keeping unauthorized parties at bay as it concerns access to protected patient information (CMS, 2018).	Centers for Medicare and Medicaid Services. (2018). HIPAA basics for providers: privacy, security, and breach notification rules. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/hipaaprivacyandsecuritytextonly.pdf
5.	Stringent management of identity as well as access to protected health information.	Stringent management of identity as well as access to protected health information is of considerable significance in ensuring the integrity of patient privacy since it ensures that the system only allows access to individuals who have the authority to gain access to such information (CMS, 2018).	Centers for Medicare and Medicaid Services. (2018). HIPAA basics for providers: privacy, security, and breach notification rules. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/hipaaprivacyandsecuritytextonly.pdf

Centers for Medicare and Medicaid Services. (2018). HIPAA basics for providers: privacy, security, and breach notification rules. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/hipaaprivacyandsecuritytextonly.pdf

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.	Gaining knowledge of the facts.	Before acting in a manner to tackle the issue relating to a breach in patient privacy, as in the case of Young Psychotherapists, it would be of considerable significance to engage in a clear definition of the nature of the problem. Such an action would involve evaluating the length of time in which the employees have participated in a regular forwarding of past-due bills of patients to a collection firm, as this would provide the necessary information in retracing the measures to correct the mistakes.
2.	Identifying the necessary information.	As such, the next step would involve listing all the information that would be necessary to correct the breach since if the collections firm had not gained access to highly protected patient information such as CPT codes, it could be possible to prevent the escalation of the breach. Therefore, such information is of great significance.
3.	Listing to the concerns.	Thereafter, it would be viable to list all the factors that could be of influence on the decision to help restore normalcy following the breach in privacy (ACHE, 2020). For instance, if regaining the bills to make them devoid of highly protected patient information such as CPT codes would be of great significance in ensuring the correction of the breach, it would be viable to list such a concern.
4.	Developing possible resolutions.	At this stage, it would be viable to start an active and detailed search for the potential resolutions as well as their likely outcomes (ACHE, 2020). For instance, if regaining the bills to clear the highly protected patient information such as CPT codes would be applicable, it would be essential to develop it as a resolution and the outcomes that would likely result from such a resolution.
5.	Evaluating the resolutions.	Thereafter, it would be viable to evaluate the outcomes of the resolutions in terms of legality, cost, and impact (ACHE, 2020). For instance, if regaining the bills to clear the highly protected patient information such as CPT codes would be legal, cost effective, and associated with good outcomes, it would be viable
6.	Recommending an action.	At this point, it would be of great significance for the leaders to realize that without an action, it would not be viable to actualize the decision aimed at resolving the issue that created the security breach in the first place (ACHE, 2020).

*Include citation. Example: https://ache.org/abt_ache/EthicsToolkit/JA15_ethic_reprint.pdf

American Collage for Healthcare Executives. (2020). Ethical Decision Making for Healthcare Executives. Retrieved form https://www.ache.org/about-ache/our-story/our-commitments/ethics/ache-code-of-ethics/ethical-decision-making-for-healthcare-executives

Conclusion

In summation, there are a number of practice that health care professionals may overlook while in real sense they are actual violation of HIPAA and breaches in patient privacy. Following the determination of the significance of the confidentiality, security, privacy in ensuring high quality patient care, HIPPA came up with the Privacy Rules. The Privacy Rule not only offers the patient the right in respect to health information but also limits the use and sharing of patient information with other parties (McCoy & Perlis, 2018). While confidentiality is the right of protecting vital health care information from disclosure to the public domain, and security the process through which such information attracts protection from external threats, privacy refers to the right to conceal such information from the reach of unauthorized personnel. Compliance to patient privacy is important since it has proven its effectiveness in ensuring that internal stakeholders and the health care organization stay safe from such consequences as loss of job due to termination as a result of incompetency, decline in customer confidentiality due to breach in private information, and decline in revenue generated by the health care organization due to decline in consumer volume (Yaraghi & Gopal, 2018). As such, for future practice, it would be viable to monitor such engagements as conducting internal auditing as well as monitoring and designation of compliance officer as well as compliance committee. For such achievements, it would be important to employ such resources as supervisors, educators and trainers on information technology, computers, and virtual private networks.

References

Department of Human and Health Services. (2020). The Privacy Act. Retrieved from https://www.hhs.gov/foia/privacy/index.html

Koskimies, E. M., Koskenniemi, J., & Leino-Kilpi, H. (2020). Patient’s informational privacy in prehospital emergency care: Paramedics’ perspective. Nursing Ethics, 27(1), 53-66.

McCoy, T. H., & Perlis, R. H. (2018). Temporal trends and characteristics of reportable health data breaches, 2010-2017. Jama, 320(12), 1282-1284.

Puri, V., Kaur, P., & Sachdeva, S. (2020). Effective Removal of Privacy Breaches in Disassociated Transactional Datasets. Arabian Journal for Science and Engineering, 1-16.

Yaraghi, N., & Gopal, R. D. (2018). The role of HIPAA omnibus rules in reducing the frequency of medical data breaches: Insights from an empirical study. The Milbank Quarterly, 96(1), 144-166.

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