Seven Essential Elements of an Effective Compliance Program 

Number  Element of an Effective Compliance Program (Federal Register)*  How Does This Element Apply to the Privacy Breach/HIPAA Violation? 
1.  Training and educating employees on HIPPA privacy laws (Gajwani et al., 2022).   This measure would apply to Villa health because the employee who shared the information did not have information on the regulations about sharing medical information. If the employee could have been subjected to effective training on these issues, they could not have violated the policy. The design and implementation of a system such as HIPPA policies require the collaboration and participation of every team member. Identifying relevant team members that can effectively perform designed tasks and responsibilities is vital. Since a HIPPA policy implementation needs to incorporate medical data from various departments, it is imperative to draw team members from multiple departments. In addition, it is vital to integrate various systems to offer the needed information in real-time effectively 
2.  Adopting an effective communication platform between supervisors and employees in the clinic (Gajwani et al., 2022).   At Villa Health, the process of sharing medical information with the insurance provided is unclear, and employees seem to lack an understanding of the entire process. If the clinic had a better line of communication regarding such issues, the employees would not have shared the medical information without the employee’s consent.   
3.  Tasking compliance officers and compliance committee on such issues (Gajwani et al., 2022).   The compliance officer and the committee will prevent Villa Health from facing such issues as they will be investigating all the situations and ensuring that they align with the required health policies in healthcare.  
4.  Writing policies, standards of conducts, and procedures for access by employees at any time (Gajwani et al., 2022).    This procedure would allow employees to remind themselves of the healthcare policies, including the recent changes in HIPPA regulations. Villa Health employees would remain updated on the policies which would limit such violations within the clinic.  
5.  Developing a quick response to any form of offense at the clinic and undertaking a fast and corrective actions (Gajwani et al., 2022).   This applies to the presented case at Villa Health because the committee with increased its speed in correcting problems before they affect the normal operation of the clinic.  
6.  Effective internal auditing and monitoring (Gajwani et al., 2022).  The internal auditing and monitoring process would allow Villa health to examine the breach’s impact and develop measures that would limit the clinic from facing such violations.  
7.  Implementing standards by developing disciplinary guidelines that each employee would have the chance to read (Gajwani et al., 2022).   This would apply to the Villa Health breach because the human resource department and the legal team will be working in unity to identify the breach’s impact and promote learning among employees of such cases.  

Privacy Breach Consequences 

Covered Entity  Legal penalty (ies)*  Additional Consequences 
Individual Leader Within Health Care Organization  The employee responsible for the violation will face the punishment of the Tier A penalties. This would include a fine of $100 on each violation (Heath et al., 2021).    Villa Health’s supervisory team would subject the employee to additional training and place the employee on probation for one month or give a warning letter regarding her conduct.  
Other Internal Health Care Organization Stakeholders  The compliance officer would as well face the legal penalty for not offering the required training and cross-examining the conduct of the employees a


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