Sanction Policy

5. Procedures

1. VIOLATION CATEGORIES AND PROGRESSIVE DISCIPLINE

Level 1 — Minor/Inadvertent Violations: Unintentional errors with low potential for unauthorized access or disclosure. Examples: forgetting to log off a workstation, discussing patient information in a semi-public area without realizing others could overhear, sending a fax to the wrong number. Note: any impermissible use or disclosure of unsecured PHI (such as a misdirected fax) is presumed to be a reportable breach under 45 CFR § 164.402 unless [PRACTICE NAME] documents, through the four-factor risk assessment, a low probability that the PHI was compromised. The sanction level addresses the workforce member's conduct and is determined separately from, and does not substitute for, the breach risk assessment required by the Breach Notification Policy. Sanction: Verbal counseling and re-training. Documented in the employee's file.

Level 2 — Moderate Violations: Careless or negligent actions that resulted in or could have resulted in unauthorized access or disclosure. Examples: sharing login credentials, leaving printed PHI unattended in a public area, failing to encrypt a laptop containing ePHI. Sanction: Written warning and mandatory re-training. Documented in the employee's file. Second occurrence may escalate to Level 3.

Level 3 — Serious Violations: Knowing or reckless disregard for policies that results in unauthorized access, use, or disclosure. Examples: accessing patient records without a treatment, payment, or operations purpose ("snooping"), failure to report a known security incident, repeated Level 2 violations after counseling. Sanction: Suspension without pay (duration determined by severity) and mandatory re-training. Documented in the employee's file.

Level 4 — Severe/Willful Violations: Intentional or malicious actions involving PHI. Examples: selling or disclosing PHI for personal gain, deliberate sabotage of security controls, stealing patient information, identity theft. Sanction: Immediate termination of employment. Referral to law enforcement and HHS Office for Civil Rights as required.

2. INVESTIGATION PROCESS

2.1 All reported or suspected violations shall be investigated by the Privacy Officer and/or Security Officer within [NUMBER] business days of the report.

2.2 The investigation shall include: documentation of the alleged violation, interview of the workforce member involved, review of relevant audit logs or system records, assessment of whether a breach occurred that requires notification, and determination of the appropriate sanction level.

2.3 The workforce member shall be given an opportunity to provide their account of events before a sanction is imposed.

2.4 The Privacy/Security Officer shall consult with [PRACTICE ADMINISTRATOR/HR MANAGER/LEGAL COUNSEL] before imposing Level 3 or Level 4 sanctions.

3. DOCUMENTATION

3.1 All sanctions shall be documented, including the violation description, investigation findings, sanction imposed, and any required follow-up actions.

3.2 Sanction records shall be maintained for a minimum of six (6) years per 45 CFR § 164.530(j).

4. NON-RETALIATION

4.1 [PRACTICE NAME] shall not intimidate, threaten, coerce, discriminate against, or take retaliatory action against any workforce member who in good faith reports a HIPAA violation, files a complaint with HHS, or participates in an investigation, per 45 CFR § 164.530(g).

4.2 Any workforce member who retaliates against a reporter shall be subject to sanctions under this policy.

6. Roles & Responsibilities

Privacy Officer ([PRIVACY OFFICER NAME]): Receives reports of suspected Privacy Rule violations. Leads or participates in violation investigations. Determines appropriate sanctions in consultation with practice leadership. Maintains sanction documentation.

Security Officer ([SECURITY OFFICER NAME]): Receives reports of suspected Security Rule violations. Reviews audit logs and system evidence during investigations. Determines appropriate sanctions for security violations in consultation with practice leadership.

Practice Administrator ([ADMINISTRATOR NAME]): Approves Level 3 and Level 4 sanctions. Ensures sanctions are applied consistently and without discrimination. Coordinates with legal counsel and HR as needed.

All Workforce Members: Know and comply with all HIPAA policies and procedures. Report suspected violations to the Privacy or Security Officer. Cooperate fully with investigations.

7. Review Schedule

This policy shall be reviewed at least annually and updated as needed to reflect changes in regulations, organizational structure, or enforcement experience. The annual review shall assess whether sanctions have been applied consistently and whether the policy is effective in deterring violations.

8. Regulatory References

45 CFR § 164.308(a)(1)(ii)(C) — Sanction policy (Required) 45 CFR § 164.530(e) — Sanctions for Privacy Rule violations 45 CFR § 164.530(g) — Retaliation and intimidation prohibited 45 CFR § 164.530(h) — Waiver of rights prohibited 45 CFR § 164.530(j) — Documentation retention (6 years) 42 U.S.C. § 1320d-5 — Civil monetary penalties for HIPAA violations 42 U.S.C. § 1320d-6 — Criminal penalties for wrongful disclosure of PHI