QUALITY IMPROVEMENT
HIPAA PRIVACY POLICY
Staff confidentiality of Protected Health Information (PHI) and Minimum Necessary
Authorizations for Use and Disclosure
Disclosures of PHI for Treatment, Payment and Operations; Data Use Agreements and Limited Data Sets
Review of HIPAA Notice of Privacy Practices
Posting and availability of Notice of Privacy Practices
Privacy of Confidential HIV Information
Uses and disclosures of PHI – Special Circumstances
Privacy of Mental Hygiene Information
Privacy of Psychotherapy Notes
Requests for Additional Privacy Protections
Event Reporting Policy and Procedures
148 - Report on Actions Taken Procedure
149 - Investigative Reports Procedure
150 - Investigative Summaries Procedure
After-Hours Administrative Notification Procedure
Event Report Documentation Procedure
Guidelines for Appointment Refusal - Event Documentation
HIPAA and Missing Person Protocol addendum
Incident Notification Procedure
Minor Notable Occurrence Procedure
Missing Person Protocol v2 519
Preliminary Assessment Procedure
Reportable Incident - Abuse and Neglect Procedure
Reportable Incident - Significant Procedure
Requests for Incident Report Information Procedure
Response to Investigation Procedure
CORPORATE COMPLIANCE
Board Resolution Regarding Compliance
Responsibilities of the Board of Directors Regarding Compliance
Communication of Compliance Activities to the Board of Directors
Compliance-related Training and Communication
Criminal History Record Checks
Anti-kickback, Inducement and Physician Arrangements
Staff Performance, Incentives and Discipline
Preventive Risk Assessment and Annual Compliance Activity Planning
Agency-wide Service Delivery Standards
Accurate and Timely Documentation of Services
Internal Monitoring & Auditing
Non-Compliance Detection and Response, and Confidential Communications
Management of Situations Reported to the Compliance Office
Risk Appetite Assessment of Compliance Matters
Unsupported Claims, Repayment and Voluntary Self-Disclosure
Employee Response to Governmental Investigations
Political Contributions and Lobbying
New Government Initiatives related to Compliance