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 (for example, Joint Commission’s National Patient Safety Goals 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, and governmental and regulatory agencies that 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 that may pertain to your compliance recommendations.

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 a 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 violations 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 laws.

· 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.

. 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 the current APA format. 

· Length: Approximately 8–10 typed, double-spaced content pages in Times New Roman, 12-point font, including the reference page. See the 
APA 7th Edition Example Paper [PDF]
.

· 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 the current APA format.

· References: Include a minimum of six current, authoritative citations and references in the current APA format. See 
Evidence and APA
 for more information.

· Scoring guide: Please review the scoring guide for this assessment so that you understand how your faculty member will evaluate your work.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and 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 the expectations of 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.

Hi  all,

I am here to help you succeed Here are some tips:

1. The templates are only for use in organizing your work before writing the 8-10 page essays.

2. Use proper APA formatting per the 7th edition. 

3. Download a free copy of Grammarly and use it to check your work and make corrections before submitting your assignment.

4. Use headings to organize your work. Be sure they are in order of the scoring guide to create a logical flow of information.

5. Avoid the use of first-person in scholarly writing. 

6. These assignments require multiple examples from multiple authoritative sources.

I look forward to seeing your submissions. 

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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.

1

2

1

Zombies: How to Survive the Apocalypse

Anne Rojas

National American University

EN 1300: Composition II

Jacey Moran

July 17, 2020

This is not a full APA paper. It is meant to

show students the basics.

Students should contact their instructor or a

librarian for specific questions.

2

Abstract

An abstract is a summary of your paper, usually between 150 and 250 words long. It should

include your thesis statement and describe what your paper is about and the key points of your

research. Abstracts should be simple and to the point, allowing the reader to decide if he or she

wants to read your paper in its entirety. Please also note that the first line of your abstract is not

indented.

Keywords: zombies, apocalypse, preparation

(An abstract is optional for student papers. Please ask your instructor whether an abstract should

be included in your paper.)

3

Zombies: How to Survive the Apocalypse

The continuing threat of a zombie apocalypse requires heightened awareness and

preparation in order to survive. There is a need for the availability of public health resources and

survival techniques. In addition to public resources, individuals will have to take the initiative to

be aware and prepare. Focus on development and implementation of resources will prove to have

a high return on investment; preparedness will ensure survival of the human species.

Procrastination will lead to being assimilated into the zombie ranks.

One of the first things everyone can do to prepare for the arrival of zombies is to stock up

on water, food, batteries and candles. Having the proper supplies is an important step in being

ready in the event of an outbreak. The Office of Public Health has excellent information on what

you can do to get ready (Centers for Disease Control and Prevention, 2012).

Some people think it is frivolous to prepare for the eventuality of a zombie apocalypse.

A zombie apocalypse is something for which even the United States military trains (Mulrine,

2012). This indicates that civilians should be taking the threat seriously and heeding the advice

of not only the government but the military as well.

Other considerations have to be taken into account by those in the legal field, including,

“examining the critical question of whether the undead should be considered dead for estate tax

purposes” (Chodorow, 2013, p. 1207). It would be difficult to recoup assets once an estate has

been distributed; verification of the status of the deceased is critical before the probate process

begins.

This exercise highlights the flawed assumption that lies at the heart of our tax code –

namely, that death is permanent – and reveals Congress’s complete lack of foresight in

designing the nation’s tax laws. In light of the difficulties of applying existing tax law to

4

Direct quotes

that are 40

words or

more should

be indented

without

quotations

marks. The

in-text

citation

comes after

the period.

the undead, it may well be that Congress needs to create new laws for the undead, or

possibly even different laws for different types of undead. The point here is not to

advocate for any particular solution. Instead it is to highlight the problem and convince

Congress and the Internal Revenue Service (“IRS”) that they must act now, before it is

too late. (Chodorow, 2013, p. 1207)

Chodorow’s assertion that Congress needs to amend our public laws in order to properly deal

with the undead is an interesting one.

REMINDER: All sources listed on the reference

page must be cited somewhere in the body of the

paper; anything cited in the body of the paper

must be listed on the reference page.

5

References

Centers for Disease Control and Prevention. (2012). Zombie preparedness.

https://www.cdc.gov/phpr/zombies.htm

Chodorow, A. (2013). Death and taxes and zombies. Iowa Law Review, 98(3), 1207-1231.

Jacobs, J. H. (2012, July 14). 10 essentials for surviving the zombie apocalypse: A practical

guide. Huffington Post. https://www.huffingtonpost.com/john-hornor-jacobs/10-

essentials-for-survivi_b_1658924.html

McCullough, J. A. (2013). Zombies: A hunter’s guide. Osprey Publishing.

Mulrine, A. (2012, October 31). No prank: On Halloween, US military forces train for zombie

apocalypse. Christian Science Monitor. https://www.csmonitor.com

Pastor, P. (2013). The zombie apocalypse. Christianity Today, 57(1), 80.

http://www.christianitytoday.com/ct/2013/january-february/zombie-apocalypse.html

Peisner, D. (2012, November 8). Secrets of the zombie factory. Rolling Stone.

https://www.rollingstone.com/movies/news/the-walking-dead-secrets-of-the-zombie-

factory-20121026

7/18/22, 9:26 PM Compliance Program Implementation and Ethical Decision Making Scoring Guide

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Compliance Program Implementation and Ethical Decision Making Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED

Summarize the
relevant health care
compliance
concepts that apply
to a HIPAA privacy
breach.

Does not
summarize the
relevant health
care compliance
concepts that apply
to a HIPAA privacy
breach.

Attempts to summarize
the relevant health care
compliance concepts
that apply to a HIPAA
privacy breach; however,
omissions and/or errors
exist.

Summarizes the
relevant health
care compliance
concepts that
apply to a HIPAA
privacy breach.

Summarizes the relevant
health care compliance
concepts that apply to a
HIPAA privacy breach.
Summary includes
multiple examples,
specifics, and references
to current, authoritative
sources to explain
concepts.

Apply the seven
essential elements
of an effective
compliance program
to a HIPAA privacy
breach.

Does not apply the
seven essential
elements of an
effective
compliance
program to a
HIPAA privacy
breach.

Attempts to apply the
seven essential
elements of a effective
compliance program to a
HIPAA privacy breach;
however, omissions
and/or errors exist.

Applies the seven
essential elements
of an effective
compliance
program to a
HIPAA privacy
breach.

Applies the seven
essential elements of an
effective compliance
program to a HIPAA
privacy breach. Narrative
includes multiple
examples, specifics, and
references to current,
authoritative sources.

Recommend
evidence-based
actions to address a
HIPAA privacy
breach.

Does not
recommend
evidence-based
actions to address
a HIPAA privacy
breach.

Attempts to recommend
evidence-based actions
to address a HIPAA
privacy breach; however,
recommendations are
not always evidence
based or appropriate.
Omissions and/or errors
exist.

Recommends
evidence-based
actions to address
a HIPAA privacy
breach.

Recommends multiple
evidence-based actions to
address a HIPAA privacy
breach.
Recommendations
include multiple
examples, specifics, and
references to current,
authoritative sources.

Describe a health
care, industry-
approved, ethical
decision-making
framework.

Does not describe
a health care,
industry-approved,
ethical decision-
making framework.

Attempts to describe a
health care, industry-
approved, ethical
decision-making
framework; however,
omissions and/or errors
exist.

Describes a health
care, industry-
approved, ethical
decision-making
framework.

Applies an industry-
approved ethical decision-
making framework to the
problem of a HIPAA
privacy breach. Narrative
includes multiple
examples, specifics, and
references to current,
authoritative sources.

Provide a synopsis
of the
consequences to
individual leaders
and other internal
stakeholders of not
addressing a HIPAA
privacy breach.

Does not provide a
synopsis of the
consequences to
individual leaders
and other internal
stakeholders of not
addressing a
HIPAA privacy
breach.

Attempts to provide a
synopsis of the
consequences to
individual leaders and
other internal
stakeholders of not
addressing a HIPAA
privacy breach; however,
omissions and/or errors
exist.

Provides a
synopsis of the
consequences to
individual leaders
and other internal
stakeholders of
not addressing a
HIPAA privacy
breach.

Provides a succinct,
substantive synopsis of
the consequences to
individual leaders and
other internal
stakeholders of not
addressing a HIPAA
privacy breach. Synopsis
includes multiple
examples, specifics, and
references to current,
authoritative sources.

7/18/22, 9:26 PM Compliance Program Implementation and Ethical Decision Making Scoring Guide

https://courserooma.capella.edu/bbcswebdav/institution/BHA-FPX/BHA-FPX4006/220100/Scoring_Guides/a01_scoring_guide.html 2/2

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED

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.

Does not 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.

Attempts to write a clear,
well-organized, and
generally error-free
workplace brief
addressing a HIPAA
privacy breach that is
reflective of professional
communication in the
health care field;
however, significant
lapses, omissions,
and/or errors exist.

Writes 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.

Writes a clear, concise,
well-organized and error-
free workplace brief
addressing a HIPAA
privacy breach that is
reflective of professional
communication in the
health care field.