BHA FPX 4006 Assessment 1 Compliance Program Implementation and Ethical Decision Making

BHA FPX 4006 Assessment 1


This brief describes a recent HIPAA violation at our organization. While attempting to conduct a surgical procedure pre-authorization, an employee sent clinical documents including protected health information (PHI) to an insurance company by fax. The insurance company’s customer support representative contacted the employee’s supervisor, explaining that additional talks concerning the patient’s care could only occur with the patient’s written agreement. The (U.S. Department of Health and Human Services, 2022) allows a covered entity to release PHI for treatment, payment, or healthcare operations without patient consent. However, the hospital where this event happened is in Minnesota, which has tougher restrictions for patient health information, resulting in a HIPAA violation (The HIPAA Journal, 2019).

Other Assessment:
NURS 4020 Assessment 2

Problem Summary: Privacy Breach – HIPPA Violation

When an organization experiences a HIPAA violation, it must adhere to numerous laws, regulations, and industry standards.  Vila Health, which runs hospitals in Minnesota, is subject to the state’s stricter patient health record rules and HIPAA. Minnesota hospitals must get written patient agreement before releasing any protected health information, including to other healthcare providers (Minnesota Legislature, 2021). Furthermore, the Joint Commission’s accreditation criteria include laws regarding HIPAA infractions. Depending on the gravity of the violation, the organization could risk losing its accreditation.

The legislation known as the HITECH Act created the HIPAA breach notification standards. Depending on the significance of the breach, notifications must be given to the patient, the United States Department of Health and Human Services, and, if necessary, the media. In this situation, the HIPAA breach must be disclosed to both the patient and the US Department of Health and Human Services. The HITECH Act also includes an enforcement regulation that specifies the financial penalties for HIPAA infractions (U.S. Department of Health and Human Services, 2019). Because this breach is not regarded as severe, the financial consequences would be limited.

Human resource standards play a crucial role when addressing a HIPAA violation.  Human resources are responsible for creating and maintaining organizational guidelines, as well as providing training and staff development. They would be engaged in deciding the repercussions for the employee who violated HIPAA and resolving any re-training needs. The Security Awareness and Training standard requires all workers to complete particular security and awareness training, including periodic reminders of rules and procedures (American Healthcare Compliance, 2023). The training or education program previously completed by the employee engaged in the breach would have to be re-evaluated for any weaknesses.

Seven Essential Elements of an Effective Compliance Program

The first essential element of a compliance program is the creation and dissemination of organizational standards, rules, and procedures to workers (HIPAA Journal, 2023; Pererva et al., 2021). The employee implicated in the HIPAA breach should have received HIPAA training upon employment. An inquiry must be done to determine what training the employee received and the efficacy of the training program. The third critical component is the roles of the compliance officer and compliance committee, who are in charge of developing and managing compliance programs (HIPAA Journal, 2023). The compliance officer and committee can interview the employee to determine the cause of the compliance program’s failure.

Regular training is the third critical component of a successful compliance program (HIPAA Journal, 2023). This training should consist of extensive educational sessions. Documentation detailing the programs completed by the employee could be sought to ensure that they have a comprehensive working knowledge and comprehension of HIPAA regulations at the time of the breach. The fourth critical need is the presence of many open communication lines between workers and the compliance officer (HIPAA Journal, 2023). These open channels enable employees to express any areas of concern that might result in a HIPAA violation before it occurs.

The fifth and most important component of a successful compliance program is regular audits. These audits must be carried out regularly and continually monitored to assess the program’s performance (HIPAA Journal, 2023). This approach helps the compliance officer and committee develop or improve compliance initiatives. Monitoring can determine if the occurrence was a one-time HIPAA breach or if there is a major underlying issue that could result in future violations. Disciplinary action is the sixth important ingredient. Disciplinary action must be taken against the employee and any other agents who break compliance requirements (HIPAA Journal, 2023). The disciplinary action for this employee should take into account their knowledge and awareness of HIPAA requirements before the infraction.

The final component of a successful compliance program is an inquiry. When a breach or suspected violation of the compliance program occurs, an investigation and corrective action are required (HIPAA Journal, 2023). The investigation should seek to determine the fundamental cause of the HIPAA breach and execute an action plan to address and correct the problem.

Privacy Breach Consequences

The consequences of a privacy violation can differ greatly depending on its severity. The employee might incur civil fines ranging from $100 to $25,000 (Alder, 2022). Criminal charges and jail are also conceivable, depending on the severity and purpose of the offense (Lewis, 2022). Personal legal action can be filed against the employee, either by the hospital or on behalf of the patient. Termination of employment is another possible outcome. In addition, depending on the severity of the HIPAA violation, the employee can lose their state licensing.

Other stakeholders in the organization could face restrictions as a result of the HIPAA breach. If the root cause investigation reveals a weakness or flaw in the compliance program that contributed to the violation, the compliance officer and/or compliance committee could face sanctions (Armour et al., 2020). Furthermore, if the compliance officer and members of the compliance committee are determined to be responsible for the breach, they could face the firing procedure.

There are substantial consequences for the organization as well. The organization can face financial penalties based on the type and severity of the HIPAA breach (Alder, 2022). In addition, constant HIPAA breaches could result in the loss of Joint Commission certification. The organization’s reputation and community trust could suffer. Furthermore, significant or frequent HIPAA violations can result in Medicare or Medicaid reimbursement denial (HIPAA Journal, 2022). These effects highlight the significance of strong compliance mechanisms and prompt remedial action in healthcare settings.

Evidence-Based Recommendations

We’ll analyze five recommendations based on evidence. It is advised to routinely review and update the existing patient consent form to effectively handle the HIPAA breach. This form should be carefully maintained to ensure that all current regulatory and federal requirements are satisfied, and that patient information is managed and disseminated in compliance with the legal standards established by the United States Department of Health and Human Services (Gliklich et al., 2020). This proactive strategy not only improves compliance but also reduces the likelihood of future breaches involving patient information management.

Additionally, specific training for the individual implicated in the breach is critical. This training should particularly cover HIPAA regulations and procedures, emphasizing the significance of protecting protected health information (PHI) (U.S. Department of Health and Human Services, 2022b). Following the training, it is recommended to document the session and provide a formal written warning to the employee, underlining the importance of HIPAA compliance. Monitoring an employee’s adherence to HIPAA laws over time helps reaffirm their awareness and commitment to protecting patient privacy and confidentiality.

Another recommendation is to conduct a detailed root cause analysis to determine the underlying issues that contributed to the HIPAA breach (Singh et al., 2024). This study should include assessing the incident’s unique circumstances, investigating any systematic weaknesses within the compliance program, and recommending opportunities for improvement. Understanding the fundamental cause allows the firm to take focused corrective actions to prevent future breaches and boost overall compliance processes.

Furthermore, improving monitoring and auditing mechanisms is critical to ensuring continued compliance with HIPAA laws. Regular audits should be performed to evaluate the efficacy of current policies and processes, as well as to ensure that personnel conform to HIPAA regulations (Office for Civil Rights (OCR), 2019). These audits are used not just to uncover future vulnerabilities, but also to assess the effectiveness of remedial actions adopted following a breach. Continuous monitoring maintains a compliance culture within the company and helps to reduce the risks connected with unlawful disclosure of patient information.

Lastly, clear channels of communication between employees and the compliance officer are essential. Employees should feel comfortable reporting concerns or possible violations without fear of reprisal. Open communication helps the early detection and settlement of compliance concerns, allowing proactive measures to be taken to prevent infractions before they occur. By creating an open and supportive atmosphere, the organization can increase its overall compliance efforts while maintaining the confidence and confidentiality demanded by patients and regulatory authorities alike.

Ethical Decision-Making Framework for Health Care Leaders

In ethical decision-making models, the first step is to recognize the circumstances around the violation (Mökander et al., 2021). This involves determining the fundamental cause of the infraction in order to establish an effective action plan for preventing future incidences. Following this, the ethical question must be clearly defined. This phase involves investigating the ethical conflict or dilemma that resulted in the breach (Taquette & Souza, 2022).

The third phase in the framework is to evaluate the ethical healthcare principles and organizational values that apply to the scenario. It is critical to determine how these ethical standards and ideals apply to the infraction. This entails determining which specific values or principles could have been neglected or overlooked in the acts that led to the violation (Varkey, 2021). Understanding these fundamental features is critical for properly addressing the ethical dimensions of the issue and directing subsequent decision-making processes.

The fourth step is to determine the available resolution alternatives. This necessitates developing alternative remedies targeted at preventing or reducing the likelihood of the violation repeating (Tamminga et al., 2023). These solutions should take into account ethical issues, organizational policies, and practical feasibility in addressing the core reasons identified in previous rounds.

Following an exploration of possibilities, the fifth step is to suggest a specific response. An action plan should be created to adopt the preferred alternative as established by corporate leadership (Penn State Extension, 2019). This strategy should include specific measures, responsibilities, and dates for properly addressing the ethical issue and preventing future breaches.

Finally, the sixth phase involves anticipating and preparing for potential ethical dilemmas. This includes thinking about why the ethical dilemma that resulted in the breach happened in the first place. Understanding these underlying issues allows firms to proactively develop strategies to avoid such ethical problems in the future (Penn State Extension, 2019). This continuous thought and preparation are critical for upholding ethical norms and developing an integrity culture in healthcare settings.

Conclusion – BHA FPX 4006 Assessment 1 Compliance Program Implementation and Ethical Decision Making

Ethical decision-making frameworks and compliance program execution must be integrated comprehensively to effectively resolve a HIPAA breach. Healthcare organizations can enhance their compliance efforts and reduce the risk of future breaches by thoroughly evaluating and revising organizational rules, providing focused training, and creating rigorous monitoring and auditing mechanisms. Furthermore, cultivating a culture that emphasizes open communication and ethical standards is critical to preserving patient confidence and regulatory compliance. By following these principles, organizations can manage the intricacies of healthcare privacy legislation while maintaining the highest levels of patient care and confidentiality.


BHA FPX 4006 Assessment 1: Alder, S. (2022, January 23). What are the Penalties for HIPAA Violations? HIPAA Journal.

BHA FPX 4006 Assessment 1: American Healthcare Compliance. (2023). Human Resources Play a Key Role in Ensuring HIPAA Compliance. Https://

BHA FPX 4006 Assessment 1: Armour, J., Gordon, J., & Min, G. (2020). Taking Compliance Seriously. Yale Journal on Regulation, 37, 1.

BHA FPX 4006 Assessment 1: Gliklich, R. E., Leavy, M. B., & Dreyer, N. A. (2020, September 1). Principles of Registry Ethics, Data Ownership, and Privacy.; Agency for Healthcare Research and Quality (US).

BHA FPX 4006 Assessment 1: HIPAA Journal. (2022, January 2). The Most Common HIPAA Violations You Should Be Aware Of. HIPAA Journal.

BHA FPX 4006 Assessment 1: HIPAA Journal. (2023, March 30). The Seven Elements of a Compliance Program. HIPAA Journal.

BHA FPX 4006 Assessment 1: Lewis, C. (2022). Risk-Based Sentencing and the Principles of Punishment Risk-Based Sentencing and the Principles of Punishment. Journal of Criminal Law and Criminology Journal of Criminal Law and Criminology, 112.

BHA FPX 4006 Assessment 1: Minnesota Legislature. (2021). Sec. 144.293 MN Statutes.

BHA FPX 4006 Assessment 1: Mökander, J., Morley, J., Taddeo, M., & Floridi, L. (2021). Ethics-Based Auditing of Automated Decision-Making Systems: Nature, Scope, and Limitations. Science and Engineering Ethics, 27(4).

BHA FPX 4006 Assessment 1: Office for Civil Rights (OCR). (2019, November 3). HIPAA Privacy, Security, and Breach Notification Audit Program.

BHA FPX 4006 Assessment 1: Penn State Extension. (2019, May 26). The Seven Steps of Action Planning. Penn State Extension.

BHA FPX 4006 Assessment 1: Pererva, P., Kobielieva, T., Kuchinskyi, V., Garmash, S., & Danko, T. (2021). Ensuring the Sustainable Development of an Industrial Enterprise on the Principle of Compliance-Safety. Studies of Applied Economics, 39(5).

BHA FPX 4006 Assessment 1: Singh, G., Patel, R. H., & Boster, J. (2024, February 12). Root Cause Analysis and Medical Error Prevention. PubMed; StatPearls Publishing.

BHA FPX 4006 Assessment 1: Tamminga, S. J., Emal, L. M., Boschman, J. S., Levasseur, A., Thota, A., Ruotsalainen, J. H., Schelvis, R. M., Nieuwenhuijsen, K., & van der Molen, H. F. (2023). Individual-level interventions for reducing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews, 2023(5).

BHA FPX 4006 Assessment 1: Taquette, S. R., & Souza, L. M. B. da M. (2022). Ethical Dilemmas in Qualitative research: a Critical Literature Review. International Journal of Qualitative Methods, 21(21), 1–15.

BHA FPX 4006 Assessment 1: The HIPAA Journal . (2019, March 7). Is a HIPAA Violation Grounds for Termination? HIPAA Journal.

U.S. Department of Health and Human Services. (2019). HITECH Act Enforcement Interim Final Rule.

U.S. Department of Health and Human Services. (2022a, October 19). Summary of the HIPAA privacy rule.; U.S. Department of Health and Human Services.

U.S. Department of Health and Human Services. (2022b, October 19). Summary of the HIPAA security rule.; U.S. Department of Health and Human Services.

Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 30(1), 17–28.

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