| Course | EDN 812 Legal and Ethical Issues in Health Care Administration |
|---|---|
| Module | Module 2 |
| Paper type | Compliance and reporting design |
| Length | About 1,592 words, 8 pages |
| Format | APA 7 student paper |
| School | Aspen University |
| Program | Doctor of Education |
| Updated | September 2026 |
Free sample paper for EDN 812 Module 2
Sixty Days, Thirty Days, Two Hours: Building One Mandatory Reporting System for a Two-Hospital Health System
Student Name
Doctor of Education Program, Aspen University
EDN 812: Legal and Ethical Issues in Health Care Administration
Instructor Name
Month Day, Year
Sixty Days, Thirty Days, Two Hours: Building One Mandatory Reporting System for a Two-Hospital Health System
Last year Sable Creek Health missed two reporting deadlines. The composite system runs a 410-bed regional hospital, a 120-bed community hospital and a 30-bed skilled nursing unit. A malpractice payment made on behalf of a surgeon reached the National Practitioner Data Bank 47 days after payment, and a $186,000 Medicare overpayment traced to a cardiology coding error was returned five months after the billing office first flagged it. Neither delay was deliberate. Each report belonged, in practice, to whichever department happened to notice the event. This paper designs a single compliance and reporting system that makes every outside report someone's named duty, with a clock that starts on a known date.
Why Reporting Fails
Reporting failures in health systems rarely come from bad intent. They come from three gaps. Ownership is scattered, so risk management assumes pharmacy will report a drug loss and pharmacy assumes security will. Clocks are misunderstood, because many rules start the deadline when the organization identifies or discovers a problem, not when an investigation ends. And staff are unsure whether raising a concern is welcome. National evidence shows how uneven reporting can be: across 4,743 general hospitals, only 34.2% reported even one clinical privileges action to the data bank over five years, and reporting rates varied more than a hundredfold (Baldwin et al., 1999). Variation on that scale reflects local habits more than local quality.
The Foundation: An Effective Compliance Program
Reporting sits inside a compliance program, not beside it. Federal guidance describes seven elements of an effective program: written policies and procedures; a compliance officer and compliance committee; training and education; effective lines of communication, including anonymous reporting; enforcement of standards through well-publicized disciplinary guidelines; auditing and monitoring; and swift correction once a problem is found (Office of Inspector General, 2023). The same guidance stresses that a program should fit the organization's size and risks rather than copy a model document. Sable Creek already has each element on paper. What it lacks is a mechanism that turns a detected problem into a report sent on time.
The Reporting Calendar
The first design step is an inventory of every outside report the system owes. The table lists the obligations with the largest consequences, the deadline for each, the event that starts the clock and the role that owns it.
| Obligation | Deadline | Clock starts | Owner |
|---|---|---|---|
| Medicare overpayment returned to the contractor | 60 days; may be suspended up to 180 days for a timely, good-faith investigation | When the overpayment is identified | Compliance officer with revenue cycle director |
| Breach of unsecured health information affecting 500 or more people | Individuals, HHS and, where required, media: without unreasonable delay and within 60 days | Discovery of the breach | Privacy officer |
| Breach affecting fewer than 500 people | Individuals within 60 days; HHS no later than 60 days after year end | Discovery of the breach | Privacy officer |
| Malpractice payment made for a practitioner | National Practitioner Data Bank within 30 days | Date of payment | Risk manager |
| Privileges restricted over 30 days, or surrendered during an investigation | Data bank within 30 days, with a copy to the state board | Date of the action | Medical staff services director |
| Theft or significant loss of controlled substances | DEA field office in writing within one business day | Discovery of the loss | Director of pharmacy |
| Work-related death; inpatient admission, amputation or loss of an eye | OSHA within 8 hours for a death; 24 hours for the others | When the employer learns of it | Employee safety officer |
| Reasonable suspicion of a crime against a nursing-unit resident | State survey agency and police: 2 hours with serious bodily injury, otherwise 24 hours | When the suspicion forms | Skilled nursing administrator; each covered staff member |
| Serious adverse event on the state's list | State health department within 15 business days (composite state) | Identification of the event | Patient safety officer |
When the Clock Starts
Most missed deadlines are really missed start dates. The overpayment rule, the breach rule and the data bank rules all run from events the organization controls or should notice: identification, discovery or the date a payment or action occurs. Regulators treat an organization as knowing what it would have learned through reasonable diligence, so a finding that sits unread in an audit report can start a clock without anyone realizing it. Sable Creek's billing office had flagged the cardiology error in an internal audit in March, but no one treated that flag as identification, and the refund was not sent until August. The design therefore defines the start date for each obligation in writing and requires the owner to record it on the day the matter is received.
One Intake, One Calendar
Under the new design, every potentially reportable event enters through one intake point: a short electronic form that any manager can complete, linked from the incident reporting system, the compliance hotline and the revenue cycle audit log. The compliance office triages each intake within one business day, decides which obligations apply and opens a calendar entry for each with the start date, the deadline, a primary owner and a backup. Entries turn amber at half the allowed time and red three days before the deadline, and red entries go to the chief compliance officer automatically. The skilled nursing unit is the exception to the triage step, because its two-hour and 24-hour crime reports cannot wait for a next-day review; staff there report directly and inform the compliance office afterward.
Duties That Belong to Individuals
Some reporting duties rest on people, not only on the organization. Under the Elder Justice Act's crime-reporting provision, each covered staff member in a long-term care setting that receives federal funds must report a reasonable suspicion of a crime, and the facility may not retaliate against anyone who does. Licensed professionals also carry duties under state practice acts. Sable Creek's training will therefore explain which reports a nurse, physician or aide must make personally, and the policy will state that making such a report never requires a supervisor's permission.
The Hotline and Speaking Up
A reporting system depends on what people are willing to say. Qui tam litigation shows the cost of silence: in major federal fraud cases resolved over a decade, most whistleblowers were employees of the defendant organization, and the recoveries reached billions of dollars (Kesselheim & Studdert, 2008). Many of those employees had tried internal channels first. Sable Creek's hotline accepts anonymous reports by phone and web, every caller receives a case number to check progress, and the compliance office publishes a quarterly summary of the kinds of concerns raised and the actions taken, without identifying anyone.
Training
Training will be short and specific. Managers receive a 30-minute module on the reporting calendar and the intake form, built around five local cases, including the two missed deadlines. Pharmacy, medical staff services, risk management, the privacy office and the skilled nursing unit receive role-specific sessions on their own obligations, and every owner and backup must pass a scenario test each year. New managers complete the module within 30 days of hire.
Auditing the System Itself
The system must check itself. Each quarter internal audit will draw a sample of incident reports, audit findings, pharmacy discrepancy logs and employee injury records and ask two questions of each: should this have been reported, and if so, was it reported on time? The first question catches events that never reached intake; the second tests the calendar. Findings go to the compliance committee with the owner's explanation and a corrective plan.
Board Oversight
Boards are expected to oversee compliance, not manage it. Guidance prepared for health care boards asks directors to confirm that a reporting system exists, that it reaches them with timely and accurate information and that management responds to what it finds (Office of Inspector General & American Health Lawyers Association, 2015). Sable Creek's audit and compliance committee will receive a one-page dashboard each quarter and will meet privately with the chief compliance officer at least twice a year, without other executives present.
Measures
Four measures will show whether the design works: the share of reports filed on time, with a target of 100%; the median days from start date to report for each obligation; the number of reportable events found by audit that never reached intake, with a target of zero; and hotline volume with the share of concerns substantiated. A rise in hotline calls in the first year will be read as a sign of trust, not of trouble.
Ethical Grounding
Timely reporting is a legal duty, but it is also a matter of honesty. The code of ethics that the National Association for Healthcare Quality publishes for quality professionals, which the course description names, asks them to act with integrity and to communicate accurate information to those who rely on it. A late report that is technically filed still leaves regulators, patients and other hospitals working from incomplete facts for weeks. Sable Creek's policy will say so plainly in its opening paragraph.
Conclusion
Sable Creek's two missed deadlines came from scattered ownership and unclear start dates, not from dishonesty, and both causes can be designed away. A single intake point, a written start date and deadline for every obligation, named owners with backups, a quarterly audit of the system itself and board oversight turn reporting from an accident of who noticed into a routine. The design costs little beyond staff time, and it protects patients, the system's license and the trust of regulators who will read every report the system sends.
References
Baldwin, L.-M., Hart, L. G., Oshel, R. E., Fordyce, M. A., Cohen, R., & Rosenblatt, R. A. (1999). Hospital peer review and the National Practitioner Data Bank: Clinical privileges action reports. JAMA, 282(4), 349-355. https://doi.org/10.1001/jama.282.4.349
Kesselheim, A. S., & Studdert, D. M. (2008). Whistleblower-initiated enforcement actions against health care fraud and abuse in the United States, 1996 to 2005. Annals of Internal Medicine, 149(5), 342-349. https://doi.org/10.7326/0003-4819-149-5-200809020-00009
Office of Inspector General. (2023). General compliance program guidance. U.S. Department of Health and Human Services. https://oig.hhs.gov/compliance/general-compliance-program-guidance/
Office of Inspector General, & American Health Lawyers Association. (2015). Practical guidance for health care governing boards on compliance oversight. U.S. Department of Health and Human Services. https://oig.hhs.gov/documents/compliance-guidance/1107/Practical-Guidance-for-Health-Care-Boards-on-Compliance-Oversight.pdf
EDN 812 Module 2 instructions, in plain terms
Compliance and reporting to agencies is one of the processes Aspen's course description asks EDN 812 students to implement, and because the Module 2 instructions are released inside the classroom, this example shows one full design. Expect the task to ask how an organization knows what it must report, to whom and by when, and how it makes sure that happens. Start with an inventory of real obligations, not a general description of compliance. Give every obligation a deadline, the event that starts its clock and an owner by title. Explain how a problem travels from the person who notices it to the person who reports it. Show how the board learns whether the system works. Finally, test your design against the obligation with the shortest deadline, because that is usually where a process built around weekly meetings breaks down.
How this EDN 812 Module 2 example is built
The paper begins with two failures at the composite system, a malpractice payment reported 47 days after it was made and a $186,000 overpayment returned five months after it was flagged, and names three causes: scattered ownership, misunderstood start dates and uncertainty about speaking up. It grounds the design in the seven elements from federal compliance guidance and then presents a four-column table of nine obligations, from overpayments and breaches to data bank reports, controlled substance losses, OSHA injuries and crimes against nursing-unit residents. Later sections explain when each clock starts, describe a single intake form with triage within one business day, carve out the skilled nursing unit's two-hour reports, and cover individual duties, the hotline, training, quarterly self-audits, board oversight, measures and the ethics of accurate reporting.
EDN 812 Module 2 rubric: what earns full marks
Instructors usually grade a compliance design on accurate legal requirements, a workable process, clear accountability and a way to know whether the process works. The deadlines in the table match the federal rules in force in 2026, which is where accuracy marks are won or lost. Four APA sources support the design: federal compliance program guidance from 2023, joint guidance for governing boards, a JAMA study of hospital reporting to the data bank and an Annals of Internal Medicine study of whistleblower cases. Treating start dates as a separate problem from deadlines shows analytical depth that graders reward. The quarterly audit asks two questions of every sampled event, should it have been reported and was it on time, which gives the design a feedback loop rather than leaving it as a policy on paper.
EDN 812 Module 2 help: mistakes that cost marks
Students often write compliance papers that describe the seven elements in general and never name a single report the organization owes. Others list deadlines without saying when each clock starts, which is where real organizations fail. Build your table first, using the federal rules plus the two or three state reports that matter most where you work, and check each deadline against the agency's own website. Name an owner and a backup for every row. Then trace one event from discovery to report and time each step. Remember that some duties belong to individuals, not only to the organization. If you are unsure which state reports apply to your facility, your risk manager or compliance officer can usually tell you in a short conversation, and a tutor can help you turn their answer into a clear design.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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EDN 812 Module 2 questions, answered
What does EDN 812 Module 2 usually ask for?
Aspen's EDN 812 asks students to implement effective processes for compliance and reporting to agencies, so designing a compliance and reporting process for one organization is a typical second assignment. Follow your classroom prompt.
How long does a hospital have to return a Medicare overpayment?
Sixty days from identification, and current rules allow that deadline to be suspended for up to 180 days while the organization completes a timely, good-faith investigation.
What must a hospital report to the National Practitioner Data Bank?
Among other things, malpractice payments made for a practitioner and privilege restrictions lasting more than 30 days or surrendered during an investigation, each within 30 days.
Where can I find a free EDN 812 Module 2 sample paper?
It is posted in full above, a reporting system design for a two-hospital health system with a nine-row table of deadlines, start dates and owners for its mandatory reports to outside agencies.
When does a reporting deadline start?
Usually when the organization identifies or discovers the problem, and regulators treat it as knowing what reasonable diligence would have revealed, so an unread audit finding can start a clock.