Managerial Toolkit For Legal Compliance

MANAGERIAL TOOLKIT
FOR
LEGAL COMPLIANCE
Name:
Date:
BUSINESS TRANSACTOINS
1.Tool Name
Business Associate Inventory Spreadsheet
URL or Cloud pathway to access the tool

https://www.complyassistant.com/resources/tools/business-associate-inventory-spreadsheet/
Brief Description of the Tool

This toolkit provides the necessary requirement for compiling the list of business associate for Covered Entities, in compliance with OCR
Standards.
Tool Justification (Explain why you selected this tool over others)
The BA Profile section of the toolkit provides the service scope for the Covered Entity CE, stating how BAs access PHIs from the CEs, and
establishing conditions for risk assessment.
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
2.Tool Name
HIPAA Business Associate Agreement Template

https://www.complyassistant.com/resources/tools/business-associate-agreement/

The toolkit provides considerations for the relationship between a Covered Entity CE and its Business Associates, which defines creation,
acceptance, maintenance, transmission, or security of ePHI, in accordance with Section 164.314(a).
GOVERNMENT PROGRAMS
1.Tool Name
HIPAA and Health Information Privacy Compliance Toolkit

https://content.next.westlaw.com/w-002-2525?isplcus=true&transitionType=Default&contextData=(sc.Default)&firstPage=true

Resources to assist healthcare covered entities in developing, executing, and evaluating privacy and data security compliance plans that
manage individual's medical records.
It summarizes requirements from HITECH Act, Federal Trade Commission Act and FTC's Health Breach Notification Rule (16 C.F.R. §§ 318.1
to 318.9), and the Food, Drug, and Cosmetics Act. It is comprehensive.
i. Compliance against government investigations and sanctions on massive information breach.
ii. Compliance against private suit for individual information breach
iii. Maintaining a secured information reputation

i. Evaluation of IT services provider for secure infrastructure
ii. Evaluation of vulnerabilities in data governance policies
2.Tool Name
A Toolkit for Health Care Boards

https://oig.hhs.gov/documents/compliance-guidance/809/toolkit-handout.pdf

The toolkit is divided into two sections that promote quality of care and evaluate compliance program.
It is not just limited to a particular program, but enables the evaluation of other compliance standards.
i. Assessing the sovereignty of the compliance officer and processes in the organization
ii. Emphasizing the importance of compliance procedures among employees and management
iii. Assessing management’s awareness of current best practices

i. Evaluating the line of report between the compliance officer and management decision making
ii. Test employees and management’s awareness of the penalties for violating compliance standards
iii. Comparing organization’s compliance checklist with current best practices
HEALTH INFORMATION TECHNOLOGY
1.Tool Name
Remote Medical Billing HIPAA Compliance Checklist

https://www.drcatalyst.com/remote-medical-billing-hipaa-compliance-guide

Highlights the infrastructural requirements and necessities for administering remote billing in healthcare that ensures the security of
patient’s or subscriber’s information.
The toolkit summarizes the crucial requirements according to HIPAA’s four significant amendments, including; HIPAA Security Rule
Amendment of 2003, Privacy Rule Amendment of 2003, Breach Notification Rule Amendment of 2009, and Final Omnibus Rule
Amendment of 2013. It is very comprehensive.
i. Periodical audit of network infrastructure
ii. Disaster recovery procedure
iii. Network security resilience audits
iv. Customer satisfaction audit

i. To ensure that required and certified devices are implemented in the network infrastructure
ii. To follow safest and certified options to implement disaster recovery procedure for data security and retention
iii. To ensure that information is not susceptible to known threats
iv. To ensure that subscribers are not victims of complicated payment procedures.
2.Tool Name
HIPAA Compliance Software

https://compliancy-group.com/hipaa-compliance-software/

It assists covered entities in complying with the HIPAA Privacy, Data Security, Omnibus Rules, and Breach Notification, by guiding them
through the process.
It maintains a complete checklist items for compliance in the different Health Information Technology concerns, which includes Risk
Assessment for data breach, and also provide compliance checklist for breach notification
i. Preparation for data breach audit
ii. Data infrastructure risk assessment
iii. Reporting data breach

i. Notifying patients of a data breach that affects them
ii. To determine and audit the security status of the data infrastructure
PATIENT CARE
1.Tool Name
Compliance Monitoring Checklist

https://assets.hcca-info.org/Portals/0/PDFs/Resources/library/Auditing%20and%20Monitoring-Checklist.pdf

The compliance toolkit summarizes patient care considerations from different policies and healthcare division to form an 11-section
checklist for patient care administration
It is a comprehensive list that explores considerations ranging from Corporate Compliance Policy Availability and Education to Home Health
and HIPAA Compliance standards, among others, to form a standard for compliance in Patient Care.
i. Evaluating issues of conflict of interests in patient care
ii. Evaluating feedback mechanisms and how it has portrayed patients’ experiences
iii. Assessing employees’ adherence to compliance standards

i. Administration of the conflict-of-interest audit
ii. Administering direct interview on patients, and comparing with results from the feedback process
iii. Compare compliance goals and achievements
2.Tool Name
Incident Management Software

https://www.patientsafety.com/en/software/incident-management

It records close calls, provides analytics, organizes procedures, and tracks patient recovery progress.
Employees may record near-misses by filling out a simple web form, also be accessible on mobile devices, using the incident management
software. The solution provides a variety of analytical methodologies for determining the cause of an event and assisting in the
implementation of corrective steps.
i. Evaluating patient improvements
ii. Adequate near-misses record keeping for knowledge base.
iii. Record keeping for patient behaviors and aggression towards staffs

i. Store relevant information on designated forms
ii. Running data analytics for decision-making for patient care
LABOR AND EMPLOYMENT
1.Tool Name
Corporate Compliance and Ethics Toolkit
https://www.ethics.org/resources/free-toolkit/

The Corporate Compliance and Ethics Toolkit is a collection of information that is updated on a regular basis to assist in-house counsel in
understanding and addressing the many laws and rules with which a corporation must comply, as well as any concerns that may emerge.
It involves training of employees and ensuring the imbibement of the organization’s policies, while alerting the organizations to
considerations that may lead to serious violations.
i. Developing and implementing appropriate compliance standards for staff, and educating them on the company's standards.
ii. Staying updated about the many rules that the firm must follow and keeping track of their status.
iii. Identifying concerns that might lead to possible violations and putting processes in place to deal with them.

i. Routine training and seminar
ii. Compliance audit
iii. Risk assessments
2.Tool Name
Conflict-of-Interest

https://bphc.hrsa.gov/programrequirements/site-visit-protocol/conflict-interest

The toolkit ensures that employees do not have a voice in determining issues that may lead to personal benefit for them or a family
member as a result of business dealings.
While the document outlines acceptable standards, it provides actually deterrents to conflict-of-interest through agreements and written
disclosures, among others.
i. Evaluating procurement and contracting misconducts
ii. Periodic procurement audit
i. Procurement Audit
ii. Contracting and Contract Management Audit

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MANAGERIAL TOOLKIT

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Brief Description of the Tool

URL or Cloud pathway to access the tool

Brief Description of the Tool

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Tool Use (Explain how the tool will be used)

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HEALTH INFORMATION TECHNOLOGY

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Tool Use (Explain how the tool will be used)

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LABOR AND EMPLOYMENT

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Brief Description of the Tool

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