This policy is listed for reference only and should be reviewed with your lawyer before implementing them into daily practice. We are not lawyers and are not providing any legal advice. View our legal disclaimer.

Security Management: Whistleblowers

Reference: 45 CFR § 164.502
Last Updated: May 19, 2024


Goal: Provide means to employees and associates to discuss information about practices or individual conduct that violates safety or protocols without fear of been punished.

The purpose of the Whistleblower Policy is:

  • To ensure the safety of our patients
  • To prevent violations from owners, employees, agents and contractors
  • To ensure fairness and open door policy to all employees, agents and contractors.


Procedure: All employees, agents and contractors have the right to report improper behavior to any member of the management team.

  • It is recommended that any person wishing to communicate with Management complete a Communication Worksheet Form.
  • Upon receipt of the Communication Form the receiving party or is representative shall conduct an immediate investigation to confirm or deny the concerns expressed on the form.
  • Employee initiating the concern shall not be considered in violation of the Security or Confidentiality requirements regarding uses and disclosures of protected health information:
    • When the workforce member believes, in good faith, that a member of the same has engaged in conduct that is unlawful or otherwise violates professional or clinical standards,
    • When the workforce member believes that the care, services or conditions provided potentially endanger one or more individuals, workers, or the public.
    • When PHI is disclosed to investigate or otherwise oversee the relevant conduct for the purpose of reporting the allegation of failure to meet professional standards or misconduct
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