QUALITY IMPROVEMENT
HIPAA PRIVACY POLICY
Staff confidentiality of Protected Health Information (PHI)
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
CORPORATE COMPLIANCE
Delegation of Substantial Discretionary Authority
Responsibilities of the Board of Directors Regarding Compliance
Communication of Compliance Activities to the Board of Directors
Compliance-Related Training and Communication
Background and Exclusion Checks
Criminal History Record Checks
Professional Licensure and Certification Verification and Monitoring
Educational Background Verification
Inducement of People Served and Waiver of Co-Payments
Staff Performance, Incentives and Discipline
Preventive Risk Assessment and Annual Compliance Activity Planning
Agency-wide Service Delivery Standards
Medical Clinical Necessity and Utilization Review
Accurate and Timely Documentation of Services
Internal Monitoring & Auditing
Non-Compliance Detection and Response, and Confidential Communications
Classification of Compliance Concerns and Investigations
Risk Appetite Assessment of Compliance Matters
Unsupported Claims and Repayment Financial Adjustments
Employee Response to Governmental Investigations
Contractual and Financial Arrangements with Physicians
Political Contributions and Lobbying
Vendor Management
New Government Initiatives related to Compliance