~~rb9u'~or bro~lgwjjmjier document librar… · related state and federal statutes and...

California De arlment of Publlc Health

S IATEcM!:NT OF DEFICII:.Nl:IES AND PLAN OF CORRECTION

(X 1) PROVIDEWSUPPLIERICLI/\ IOEN I IHCA liON NUMBER

CA23000016

(X2) MUL llf'LI: CONSl RUCTION

A BUILDING

8 WING

PRINTED: 04/16/2012 FORM APPROVED

{X3) D/\ TE SURVEY COMPLETED

c 01/26/2012

NAME or PROVIDER OR SUPPliER

SHASTA REGIONAL MEDICAL CENTER

STREET ADDRESS, CITY, STAT£;, liP CODE

1100 BUTIE ST REDDING, CA 96001

(X4)1D PREFlX

rAG

SUMMARY STATEMCNT OF DEFICIENCIES (EACH DEf-ICIENCY MUST BF PRECEDED BY FULL

REGULATORY OH LSC IOEN IIFYING INFORMATION)

A ooo lntllal Comments

The following reflects the findings of the California Department of Public Health during an invesliyC:~liun of a co111plaint.

Complaint' 295004

The 1nspection was limited to the specific complaint investigated and does not represent the findings of a full inspect1on of the facility.

Representing the Department: 26611 , HFEN

Defic1enc1es were wntten at A 002, A 017, A 018, A 019 and A 021 for complaint 295004

A 002 Not Informed Medical Breach

Health and Safety Code Section 1280,15 (b)(2), "A clinic, health facility, agency, or hospice shall also report any unlawfu l or unauthorized access to, or use or disclosure of, a patient's medical information to the affected patient or the patient's representative at the last known address, no later than five business days after the unlawful or

I unauthorized access. use, or disclosure l1as been detected by tl1e clinic, health facility, agency, or hospice."

The CDPH verified that the facility failed to inform the affected patient(s) or the patient's representative(s) of the unlawful or unauthonzed access, use or disclosure of the patient's medical information

n ~ • t This St~tut~ l !S;not met as evidenced by .

Licensing and Certification D1vi ibrr '"

LABORATORY ~~rb9U'~OR bR"o~lgwJJMJIER STArE FORM

ID PREFIX

TAG

A 000

A 002

PROVIDER'S PLAN OF CORREC liON (I:ACII CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATe DEFICIENCY)

Shasta Regional Medica l Center Follows all HIP/\A State and Federal Laws pertaintng to pat1ent privacy. While we do not agree w ith the findings, the below indicates our corrective action for the deficiencies noted.

Shasta Regional Medical Center would like to request an informal conference regarding the deficiencies in compliance for complaint number CA002955004

Action: Policy reviewed with Chief Medical Officer, Chief Executive Officer and Director of Marl<eting regarding need to report verified privacy breact1 to patient within 5 days.

Education given to Chief Medical Officer, Chief Execu tive Officer and Director of Marketing regarding HIPAA laws.

/\11 use of patient health information outside of routine hospital business must be approved by Director of Health Information Management (Privacy Officer).

Notice was sent to the patient on 1/4/2012.

Monitoring· HIM dept to mon1tor all p(ivacy breaches for timely reporting.

Hesponsible Person: Director of Health Information Management (Privacy Officer).

UCFP1 1

I

(XS) co~•rt F rE

DArf.:.

4/23/20'12

1/16/2012

California Deoartment of Public Health

S I A f EME NT or DEFICitNCIES AND PLAN OF CORREC liON

<X I) PROVIDCR/SUPPLIER/(;LIA IDENTIFICATION NUMBER,

CA23000016

(X2) MULTIPI E CONSTRUt: liON

A. HUILOING

B WING_

PRINTED 04/16/2012 FORM APPROVED

(XJ) DA fE SURVEY COMPLE 11::0

c 01/26/2012

NAME OF PROVIDER OR :>UPPUER


STREEl AODHESS, CITY STATE ZIP CODE

1100 BUTTE ST REDOING, CA 96001

(X<\)111 PRErtX I

lAG I SUMMARY STATEMENT OF 01=.1- lt:IENCIES

(F.ACii DEI-ICIENCY MUST BE PRECEDl:D BY FULl REGULATORY OR LSC IDENTIFYING IN FORMA l iON)

A 002 Continued From page 1

ID PREriX

11\G

A002

A 017 1280.15(a) Healtl1 & Safety Code 1280 A o 17

(a) A clinic, health facility, home health agency, or hospice licensed pursuant to Section 1204, 1250, 1725, or 17 45 shall prevent unlawful or unauthorized access to, and use or disclosure of, patients' medical in formation, as defined in

I subdivision (g) of Section 56,05 of the Civil Code and consistent wit11 Section 130203. The department. after investigation, may assess an I administrative penalty for a violation of this 1 sect1on of up to twenty-five thousand dollars ($25,000) per patient wl1ose medical information was unlawfully or without authorization accessed, used, or disclosed, and up to seventeen thousand five hundred dollars ($17,500) per subsequent occurrence of unlawful or unauthorized access, use, or disclosure of that patients' medical information. For purposes of the investigation, the department shall consider the clinic's, l1ealth facility's, agency's, or hospice's l1istory of compliance with this section and ot11er related state and federal statutes and regulations. the extent to which the facility detected violations 1

and took preventative action to immediately correct and prevent past v1olations from recurring, and factors outside its control that restricted the facility's ability to comply with this section . The department shall have full discretion to cons1der all factors when determintng tl1e amount o·f an administrative penalty pursuan t to this section.

Tl11s Statute 1s not met as evidenced by· Based on Interview and record review, the facility failed to ensure that Patient 1's medical

PKOVtO!::R'S PLAN or- CORREGTIUN I (EACH CORRECTIVe AC liON SI IOUI 0 BE

CROSS·REFERENCFD ro rHI= APPROPRIATE. DEl ICIFNCYl 1

Action: Policy R002 , Release of Information and Policy 1001. Information Security, reviewed with Chief Medical Officer,

tXeiJ GOMPLFTF

VAll,

Chief Executive Officer and Director U23/20 12 of Marketing regarding proper use of patient l1ealtl1 info1 mation.

Education given to Cl1ief Medica l Officer, Cl1ief Executive Officer and Director of Marl<eting regarding HIPAA laws. 1116/2012

All use of patient health information outside of routine hospital business 1 nust be approved by the Director of l lealth Information Management (Pnvacy Officer). 1116/2012

Monitoring: Privacy Officer will monitor all privacy breaches and report results to Quality Committee.

Responsible Porson: Director of Health Information Management (Privacy Officer).

;o m () ii1

< m •• ....:J LtcenslnQ and CerttfJcatJon Dtvtslon

STATE FORM UCFP11 U ~tnu!lt•on sheet 2 of 12

California Department of Public Health

STATEMEN I OF DEFICIENCIES /\NO PLAN OF CORRECTION

tXT) PROVIDERiSUPPLlfR/CliA IDENTIFICAriON NUMBER

CA23000016

(X2) MULTIPLE CONSTRUCTION

II AUILOING ll WING _________ _

PRINTED: 04/16/2012 FORM APPROVED

(XJ} DATE SURVEY COMPLEfED

c 01/26/2012

Nt\ME Or I'ROVIDER OR SUPPLII::H


STREET ADDRCSS. GITY, STfl.TE. ZIP CODE

1100 BUTTE ST REDDING, CA 96001

1X·l)ID PREfiX

TAG

SUMMARY STATEMENT OF DFrtCICNCIES (CACII DEFICIENCY MUSl BE PkECEOED BY FULL

REGULATORY OR I SC IDENTIFYING INFORMIITION)

1\ 017 Contmued From page 2

Information was protected from unauthorized

I disclosure. This failure allowed the general public to have access to Patient 1 's medical Information I ~ Patient 1's medical information was disclosed to News Agency A; • Patient 1's medical infotmation was disclosed to News Agency B;

Patient 1's medical information was disclosed to hospital employees and medical staff; and ., Patient 1's medical informat1on was disclosed to

I News Agency C

(a) During an interview on 1/30/12 at 1-45 pm, Hospital General Council D stated he was notified that News Agency A was going to write an article regarding the hospital's care of a patient. Hosp1tal General Counctl 0 further stated that News Agency A's reporter would not release the patient's name but had provided enough details that the hospital was able to identify Patient 1 as

I the subject of the proposed news article. Hospital

I General Council D 1·evealed he received IJatient I 's medical information from Hospital Chief Executive Officer (CEO) E, then forwarded It to I Hospital Communications Director G to write a letter rebutting information from News Agency A's article Hospital General Council 0 stated he did not secure Patient 1's permission to disclose her medical information.

During an interview on 1/30/12 at 1 :40 pm, Hospital Communication Director G confirmed

I U'lat 11e received Patient ·1 's medical information I from Hospital General Council D. Hospital

Communication Director G stated he wrote and sent a rebuttal letter to News Agency A's reporter on 12/13/11 at 5·16 pm which disclosed Patient

ID PREFIX

lAG

A 017

I

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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LJc.::ns1ng and Certificallon Dtvrslon STATE I ORM UCFP11 If con11nuallon sheet 3 of 12


S fATEMENT OF DEFICtrNCIES AND I'LAN OF CORR ECTION

(X1) PROVIDER/SUPPLIER/CLIA IDI:.N f ii0 ICATION NUMBEr~ ·

(X2) MlJL r•PLE CONSl f<UC liON

A. BUILDING

CA23000016 NAMr OF PROVIDER OR SUPPLIER


B, WING _

STREET AODRFSS, CITY STAIE, lll' COD[


PRINTED 04/16/2012 FORM APPROVED

!X3/ DATE SURVEY COMPI ETED

c 01/26/2012

(X4) 10 I I'HEnX I

TAG

SUMMARY S1 ATEMENT or DEFICIENCIES (E'ACI I Or FICIENCY MUS I' BE PRECEDED BY FULL

REGULA lORY OR LSC I DEN I'IFYINC INrORMATION)

ID PREFIX

TAG

f'ROVIDFR'S PLAN 0 1- CORI~ECTION (8\CH CORRECTIVE ACTION SHOULD BE

CROSS-HEFERrNCED TO THE APPRQPRIA I I:

(ii5 ) GUMPLEI I=

DATE

A 017 Cont1nued From page 3

1

1's diagnoses, lab values , medical/health consu ltations, and discl1arge information. Patient 1 's name was not listed on this letter Hospital

I Communication Director G acknowledged that he did not secure Patient 1's permission to disclose her medical Information.

(b) During an interview on 1/26/12 at 1·25 pm, Hospital CEO E stated that on 12/16/11 , he was alerted by Hospital Media Relations Staff H that News Agency B was considering picking up the article regardmg Patient 1 from News Agency A and repnnting 1t in the1r newspaper. He further stated that News Agency 8 was asking for the hospital's comment on the article that they were going to publish regarding Patient 1. Hospital CEO E further stated he asked Hospital Cl1ief Medical Officer (CMO) F to review Patient 1 's record and do a point by point analysis of the accuracy of the Information in the article.

On 12/16/11 at 4 prn Hospital CEO E, Hospital Media Relations Staff H, and Hospital CMO F took Pat1ent 1's medical records pertaining to her admission, during early 2010, to News Agency B's Editor's office. Hospital CEO E stated that Hospital CMO F showed portions of Patient 1 's record and discussed diagnoses. progress notes, lab values. medical/health consultations. and discharge Information with News Agency B's Editor Hospital CEO E confirmed he did not secure Patien t 1 's permission to disclose her medical information.

During an interv1ew on 1/5/12 at 1·55 pm, Hospital CMO F confirmed that she had gone to the office of News Agency B's Editor with Patient 1 's record and had shown him portions of the record and discussed diagnoses, progress notes, lab values, medical/health consultations.

Licens1ng and Ce•hficat1on Divis1on STATE FORM

A0 17

DEFICifNCY)

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California Depar ment of Public Health

SfATfMFNT OF OFFICIENCIES AND PLAN OF CORRECTION

(X I) PROVIDER/SUPPLIERICLIA IDENTIFICA lION NUMBEH

CA23000016

\X2) MUUIPLE CONSTRUCTION

A BUILDING B WING _________ _

PRINTI::D. 04/16/2012 FORM APPROVED

(X3} DATE SUI<VEY COMPlrTED

c 01/26/2012

NAME OF P~OVIDER OR SUPt>LIER


S I REef ADDRESS, CITY, STATE. ZIP CODE

11 00 BUTTE ST REDDING, CA 96001

(X4) ID PREFIX

11\G

SUMMARY STATEMENl OF DU!CicNCIES (EACH DEFICIENCY MUST BE PRECEDED BY FUI L

REGULATORY OR LSC IDENTIFYING INFORMATION)


and discharge information 1n hopes to dissuade News Agency B's Ed1tor from publishing the art1cle Hospital CMO F further confirmed that she had not secured permission from Patient 1 to disclose her medical information.

On 12/22/11, News Agency B's Editor had a blog that 1ncluded an entry indicating he had chosen not to run the article from News Agency A. News Agency Editor B's blog included Patient 1's dragnosis and a consultation.

, (c) During an interview on 1/26/12 at 1:25pm, 1 Hospital CEO E stated that he issued a memo.

dated 12/20/1 1 at 9:53 am, to all hospital employees and medical staff which included a side by side analysis of News Agency A's statements and the "actual facts" which included Patient 1's physicians' assessments, lab values, diagnoses, medicallhealth consultations, and discharge information This memo did not disclose Patient 1 's name but did reference the news article published by News Agency A (wh1ch die! include Patient 1's name). Hospital CEO E stated he did not secure Patient 1 's permission to disclose her medical information.

On 1/5/12 at 12:45 pm, Staff I and J confirmed that they received the above memo, dated 12/20/'11. They stated they knew who the patrent was based on the information from News Agency A's article.

On 1/51'12 at 12:50 pm, Hospital Privacy Officer K I stated he was not conslrlted regard ing the above

memo and the first he knew of it was when lle received it.

On 1/30/12. Hosprtal CEO E was asked to produce a list of all the names of the people who

ID PREFIX

TAG

A 017

PROVIDI':H'S PLAN OF COHRECTION (EACII CORRECTIVE AC fiON SHOULD BE

CROSS·RCFrRrNCED TO THE APPROPRIATE DEFICIENCY}

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(X5) COMPLETE

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Llcenstng and Cert1ficat•on Division STI\TE FORM UCFP11 tr COOIIIIIIiii,Ofl Sheo?l 5 Cf 12


STATCMI:.N'I OF DI:.HCIENCit:S AND PLAN OF CORI<ECliQN

(X I) PI~OVIDE.RISUPI"LIER/Clli\ I DEN JIFICATION NUMBER

CA23000016

(X2) MUI Tl Pl r: CONSTRUC l iON

A BUILDING

ij,WING

PRINll:-0: 04116/20'12 FORM APPROVED

(X."\1 DATE SURVEY COMPLETED

c 01/26/2012

NAMC: OF PROVIDER OR SUPPLIF.R


STRI:.ET ADDRESS, CITY, STATE, ZIP CODE


(X4) IIJ PRFFIX

TA(;

SUMMARY STA l'EMENT OF DEfiCIE:NCI£::S !EACI I DEFICIENCY MUST 81:. PRECEDED BY FUll

REGULATORY OR LSC IOENTII·YING INFORMATION)


recerved Patient i's medicalmformation in this memo. A list of 461 employees and a list of 324 medical staff was received (total = 785 employees) .

(d) During an interv1ew on 2/ l /12 at 9'51 am, News Agency C's reporter stated he received the above memo, dated 12/20/11, in an e-mail communication on '12/27/11 at 4:08pm from Hospital Communications Director G.

On 1/4/'12, News Agency C's reporter published a news article that included a link to this memo on the Internet.

On 1/30/12 at 1:40 pm, Hospital Communication Director G confirmed that he had not secured Patient 1's permission to disclose her medical information.

On 1/26/12 al8:55 am, Patient 1's family member stated nerther she nor Patient 1 had given permission for the release of Patient 1 's medical information to anyone at or associated with the hospital.

On 1/30/12 at 3 pm, Patient 1 stated she had not g1ven permission to anyone at or associated with the hospital for the disclosure of her medical information.

I On 1/26/12 at 1:25pm, when asked what lie would do different in retrospect, Hospital CEO E stated 11e wou ld get the patient's permission first

10 PREFlX

T/\G

A017

AOI8 1280.15(b)(1)Health&SafetyCode1280 AOI8

(b) (1) A clinic, health facility, home health agency, or hospice to whicl1 subdivision (a) applies shall report any unlawful or unauthorized

I

PROVIDER'S PLAN OF CORRECTION (I:ACH CORRECTIVF ACTION SHOULD BE

CROSS-REFERENCrD TO n IE ArPHOPRI/\ IF DEFICirNCY)

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l Action: Policy reviewed with Ch1ef Medical Officer Officer, Chief Executive Officer and

I (l\5)

r;UMPLI: 1 E DATE

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I

Director of Marl<eting regarding need to 't/23/20 12 report verified privacy breach to CDPH witl1in 5 days

Ll.;en~rng and Cer1tflcatlon Division STATE rDRM ucr.., 11 II conllntraucr1 ~heel '3 or 12

California Department ot Public Health

STATEMI:NT OF DEriCIENCIES fiND PI AN OF t;ORREC l iON

(X I) I •ROVIlJERJSUPPLIFR/CLIA IDfN riFICA liON NUMBER

CA23000016

(X2) MUL I IPU: CONSTRUCTION

A BUILDING

8 WING ______ ---

PRINTED: 04/16/2012 rORM APPROVED

(X3) DA I L SURVFY i...OMI'LEI ED

c 01/26/2012

NAME OF PROVI11EP 01\ SUPPLIER


STREFT ADDRESS. ClfY SlATE ZIP C'ODE


()(.!) ID PRI:FIX

TAG

SUMMARY S'l ATEMENT OF DEFICIENCII:S WACI I OCriCIENCY MUSl 81: PHECEOED BY FULl

Rt::GULAlOIW OR I SC IDEN rii:YING INFORMATION)

i\ 018 Continued From page 6

access to, o r use or disclosure of, a pabenl's medical information to the department no later than five business days after the unlawful or

1 unauthorized access, use, or disclosure l1as been I detected by the clinic, l1ealth facility, home health

agency, or hospice. (b) (2) Subject to subdivision (c), a clinic, health facility, home health agency, or hospice shall also report any un lawful or unauthorized access to, or use or disclosure of, a patient's medical information to the affected patient or t11e patient's representative at the last known address, no later than five bus1ness days after the unlawful or unauthorrzed access, use. or disclosure has been detected by the clinic. health facility, home health agency or hospice.

This Statute rs not met as evidenced by:

10 PREFIX I

TAG

l

AO I8 I

PROVIDER'S PLAN OF CORRCCTION (EACH CORRECTIVE ACTION SHOULD GE

CROSS-REfERENCrD ro THE All PROPRIA 1 E DEf ICIENCY)

Education given to Chief Medical Officer. Cl1ief Executive Officer and Directo1· of

(X5) COMPI.CTI:

DATE

Marl<eting regarding HIPAA laws. l/I G/201 2

1\11 use of patient health information outside of routine hospital business must be approved by Director of Health Information Management (Privacy Officer). 1/ 16/20 I '~

Monitoring: Health lnfotnlation Management to monitor all p1ivacy breaches for timely reporting.

Responsible Person. Director of Health Information Management (Privacy Otficer).

1

A o 19 1280. 15(b )(2) Healtl1 & Safety Code 1280 A o 19

(b) (2} Subject to subdivision (c) a cl1n1c, healt!1 facility, home health age11cy, or hospice shall also report any unlawful or unauthonzed access to, or use or drsclosure of, a patrent's medical information to the affected patient or the patient's representative at the last known address, no later than five l:lusmess days after the unlawful or unauthorized access, use, or disclosure l1as been detected by t11e cl inic, healtll facility, home l1ealth

L1censmg and Cettn1cat1on DiVis1on STATE FORM

Action: Policy rev1ewed witll Chief Medical Office r, Chief Executive Officer and Director of Marl<etlng regarding need to report verified privacy l.)feach to patient within 5 days.

I Education given to Chief Medical Officer, Chief Executive Officer and Director of

r , I)IIE\~~WlQ• regardiny HIPAA laws. - • ...-or! ""

4 /23/20'12

1 1/16/20'12

II C<llll fiU,llion ;heel 7 of 11

03} l38=.s!j


STATCME.N f OF DEFICIENCIES AND PLAN OF CORRECTION

(X 1) PROVIDERISUPPLIER/CI.IA IOENTIFICAIION NUMBER

CA23000016

(X2) MULTIPLE CONSfRIJCTION

1\ BUILDING

B WING----------

PRINll D 04/16/2012 FORM APPROVED

!XJ) DATESIJRVEY COMPLfTFO

c 01126/2012

NAME OF 11 ROVIDER OR SUPPLICR


STREET AD DRI S:S, CITY, STATE, ZIP CODE


(X•l\ ID PRITIX

TAG

SUMMARY S I A I EMENT OF DEFICIENCIES (EACH DEFICIENCY MUS I BE PRECEDED BY FULL

REGULATORY OR LSC IDENI IFYING INFORMATION)


agency, or i1osp1ce.

Th1s Statute is not met as ev1denced by:

10 PREFIX

f/\G

A 019

f\ 021 1280. 15(d) Health & Safety Code 1280 A 02 1

(d) If a clinic, health facility, home health agency, or hospice to which subdivtsion (a) applies violates subdivision (b), the department may assess the licensee a penalty in the amount of one hundred dollars ($100) for each day that t11e unlawful or unauthorized access, use, or disclosure is not reported , following the initial five-day period spectfied tn subdivision (b) However. the total combined penalty assessed by the department under subdivision (a) and th1s

1

subdivision shall not exceed two hundred fifty thousand dollars ($250,000) per reported event.

This Statute 1s not met as ev1denced by. Based on mterview and record review. the fac1lity failed to ensure that an unauthorized disclosure of Patient 1's medical information was reported to the California Department of Public Health

I (CDPH) and to Patient 1 wtthin 5 business days after the disclosure occurred and was detected.

Finding 1

oJ ., f

I

PROVIDER'S I' LAN OF CORRECTION !EACH CORREC IWE ACTION SHOUt D 13E

CROSS RFTERENCEO TO THE Af>PROPRIA II:. DFrtCIENCY)

All use of patrent health information outside of ro~.Jtine hospr!al business m1.1st be approvecl by Director of Health lnfom1ation Mananernent (Privacy Officer)

Notice was sent to the patient on 114/20'12

Monitoring: Health Information Management to monitor all privacy breaches for timely reporting

Responsible Pl}rson: Director of Health Information Management (Pnvacy Officer) .

Action: Policy reviewed with Chief Medical

(,\!))

I t;OMPU::IE.

L\\1 F.

'1/'1(:3/21) 12

Officer, Chief Executive Officer and 4/23/20.12 Director of Marl<eting regard ing need tn report verified privacy breach to CDPI I within 5 days

I Education g1ven to Chief Medical Officer, Chief Executive Officer and Director of Marketing regarding IIIPAA laws. 1/'11:3/20 12

All use of patient health information I OLJtside of routine hospital business must be approved by Director o'f Healtll Information Management (Privacy Officer). I 1/'IG/20 12

Monitoring: Health Information Management to monitor all privacy breaches for timely reporting.

Responsible Person: Director of Health Information Managoment (Privacy Officer).

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1-A~~liOl


STI\Tt:.MI:NI Of DEFICIENCIES AND PLAN Of CORRECTION

(X I) PROVII)ERJSUPPlJERICLIA I DEN rii'ICATION NUMBFR

CA23000016

(X2) t.IUI 1 IPLE CONS rRUCTION

A BUILDING

B WING----------

PRINTED: 04/1 G/2012 FORM APPROVED

(X3) IJATE SURVEY COMPLElED

c 01 /26/201 2

NAMt=. OF PROVIDER OR SUPPLIER


S1 HEET 1\lliJRESS, CITY S rATE. ZIP CODE

1'1 00 BUTTE ST REDDING, CA 96001

(X.l} ID PREFIX

TAG

SUMMARY S II\ I EMCNT OF DEFICII:NCIES !EACII DEriCIENCY MUS f UE PRECEDED BY FULL

REGULATORY OR I SC IDEN flfYING INFORMATION)

1\021 Cont1nued From page 8

(a) On 1/30/12 at 1:45 pm Hosp1tal General Council 0 stated he rece1ved Patient 1's medical

I information from Hospital Chief Executive Officer (CEO) E. Hospital General Council 0 forwarded

I

: Patient 1's med ical information to Hosp1tal Communications Director G to write a letter rebutting misinformation that was to be published by News Agency A. Patient 1's diagnoses, lab values, medical/health consultations, and discharge informatron were disclosed in the letter, dated 12/13/11, and sent to News Agency A's

1 reporter on 12/13/11 at 5'16 pm. Hospital General Council D stated he did not secure Patient 1's permission to disclose her medical information.

The faci11ty far led to notify the COPH of lh1s disclosure of Patient 1's medical information during the five business day penod ending on 12120/11 As of 1/5/12, the date this investigation star ted. COPH determined that the facility had never notified the Department of this unauthorized disclosure of Patient 1's medical information

1 (b) On 1/26(12 at 1:25 pm, Hospital Chief Executive Officer (CEO) E stated that on 12/16/11 at 4 pm, he, Hospital Media Relations Staff H. and Hosp1tal Chief Medical Officer (CMO) F took Patient 1 's medical record for her admiss1on, 1/29/10 to 2/2/10, to News Agency B's editor's office Hospital CEO E stated that Hospital CMO F went through Patient 1's record and shared diagnoses, progress notes, lab values, medical /healtl1 consultations, and

I discharge infom1ation wlth News Agency B's reporter. Hospital CEO E stated he dld not secure Patient 1's permission to disclose her 1nedical information.

Ltcensmg and Cerlificatron Drvtsron STATE FORM

10 PREFIX

TAG

1\021

PROVIDER'S PLAN or CORRECTION (EACII CORREC11VE ACliON SHOULD BE

CROSS·RfFERENCED TO THE APPROPRIATE DETICifNCY)

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Califomia Department of Public Health

STATEMCNT OF DEFICIENCIES AN[) PI AN OF CORI'l. [ CTION

(X I) PROVIDEI'\/SUPPUEf~/CLIA IDENTIFICATION NUMBER:

CA23000016

(XZ) MUL TIPl F CONSTRUCTION

A. BUILDING

0 WING----------

PRINTED: 04/1 6/20 12 FORM APPROVED

(X3) DATE SURVEY COMPLETED

c 01/26/2012

NAMF Of I'ROVIDER 0~ SUf>PUER


SH~EET ADDRESS, CITY, STAlE l iP CODE


(X4J ID PREFIX

fAG

SUMMARY STAl EMENT OF DEFICIENCIES (EACII DEFICIENCY MUST BE PRECEDED BY FULL

RI-GULATORY OR LSC IDENTWYING INFOn MA liON)

ID PREFIX

TAG

A 021 Continued From page 9 A 021

' The facility failed to notify the COP II of this disclosure of Patient 1's medical information I during the five business day period ending on 12/23/11 . As of 1/5/12, the date this investigation started, CDPH determined t11at tl1e faci lity had never notified the Department of this unauthorized disclosure of Patient 1 's medical information.

(c) On 1/26/12 at 1:25 pm, Hospital CEO E stated that 11e issued a memo, dated '12/20/1 1 at 9'53 am, to all hospital employees and medical

I staff, which included Patient 1 's physicians' assessments, lab values. diagnoses, medical/health consultations, and discharge information. Hospital CEO E stated he did not secure Patient 1 's permission to disclose her

I medical information.

The facility failed to notify the CDPH of tl1is disclosure of Patient 1's medical information during the five business day period ending on 12/28/11 . As of 1/5/12, the date this investigation sta rted, CDPH determined that the facility had I never notified the Department of this una1.1thorfzed disclosure of Patient 1 's medical information.

(d) On 2/1/1 2 at 9:51 am, News Agency C's reporter stated he received the above memo, dated '12/20/11, in an e-mail cornmunication on 12/27/1 1 at 4:08pm from Hospital Communications Director G.

1 On i/4/1 2, News Agency C's Reporter publisl1ed a news article that included a link to this memo on the Internet.

L1censtng and Certtftcallon Dtv1s1on

STATE FORM

PROVIDER'S PLAN OF CORRECTIO N (EACH COHREC l iVE ACTION SI IOlJLD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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(1\f>) U•MPLI:: I I::

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Californ a Department of Public Health

STA 1 EMENT OF DEFICIENCIES AND PLAN OF COI~ I~EC riON

(X I) PROVIDER/SUPPLIER/CUi\ I DEN II FICA fiON NUMBER

CA23000016

(X2} MULTIPLE CtJNS rRUCTION

A BUILDING

B WING---------

PRIN'I ED: 04/16/2012 FORM APPFWVED

(X3) DATE SUFlVEY COMPLETI-0

c 01/26/2012

NAME OF PROVIDER OR SlJPPLirR


STREET /\DDfl i=SS, Cl rY, STATE, ZIP CODF


(X4) 10 PRFFIX

l AG

SUMMARY STATEMENT OF DEFICIENCIES (EI\CII DEFICIJ:;NCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IIJENTIFYINO INFORMATION)

If)

PREFIX TAG

A 021 Conlinued From page 10 A 02·1

On 1/30/12 at 1:40pm, Hospita l Communication Director G confirmed that he had not secured J=latient 1's permission to disclose her medical information.

The faci lity failed to notify the CDPH of this

1

1 disclosure of Patient 1's medical information during the five business day period ending on 1/4/12. Hospital CEO E stated the CDPI I was

I notified by mail on 1/4/12. T he CDPH had not I received a notification of this disclosure. After further review, Hospital CEO E found the letter had been sent to a wrong address. 1

1 Finding 2: I

I (a) On 1 /30/ '12 at 1.45 pm, Hospital General 1 Council D stated lle received Patient 1's medical

I informalion from Hospital Ch ief Executive Officer (CEO) E. Hospital General Council D forwarded Patient 1's medical information to Hospital Communications Director G to write a letter

1 rebutting rnfom1ation that was to be published by I News Agency A Patient 1 's diagnoses, lab

1 values, medical/health consultations, and clinical presentation were disclosed in the letter, dated

1 12/13/11, and sent to New Agency A's reporter on 12/13/11 at 5:16pm. Hospital General Council D stated he did not secure Patient 1's permission to disclose her medical information.

(b) On 1/26/12 at 1;25 pm, Hospital Chief I Executive Officer (CEO) E stated that on

12/16/11 at 4 pm, he, Hospital Media Relations Staff H, and Hospital Chief Medical Officer (CMO) F took Patient 1's medical record for her

1 admission, 1/29/10 to 2/2/10, to News Agency B's

I editor's office. Hospital CEO E stated that Hospital CMO F wen t througl1 Patient 1's record and sl1ared diagnoses, progress notes, lab

Ltcensmg and Certification D1viston

STA l E FORM

PROVIDfR'S PI AN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE

CIIOSS-RI=FERENCI=D TO r HE APPROPRIATE DEFICIENCY)

(X5) COMPI FTF

DA I£

UCFPil If cnollnuatll~l\ shee1 11 of 12

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California Department of Public Heallh

.STATEM~NT OF DI::FICIENCIES AND I' LAN tl f CORRECTION

(X I) PROVIDER/SUPPLIERfCliA IDENTIFIC/\TION NUMBER

CA23000016

(X2) MULTIPLE CONSTRl JCTION

A tlUILDING B WING _________ _

PRINTED: 04/16/20'12 FORM APPROVED

(X.3) DATE SURVEY COMPl ETW

c 01/26/2012

NAMF OF PROVIIJGR OR SUPPLIER


STREET ADDRESS. Cl l Y STATE Z IP CODE

1100 BUTTE ST REDDING, CA 9600'1

(X4J 10 I'RCIIX

1/\G

SUMMARY S1 A I EMENT OF DEFICIENCIES (EI\CH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTirYING INFORMATION)

A 02 1 Continued From page 11

values , medical/health consultations, and discharge information with News Agency B's editor. Hospital CEO E stated he did not secure Patient 1 's permission to disclose l1er medical information.

(c) On 1/26/'12 at 1 25 pm, Hospital CEO E stated H1at he issued a memo, dated 12/20/11 at 9.53 am. to all hospital employees and medical staff wl1ich included Patient 1 's physicians' assessments, lab values, diagnoses, medical/health consultations , and discharge information. Hospital CEO E stated he did not secure Patient 1 's permission to disclose her medical information.

On 1/26/12 at 125 pm, Hospital CEO E stated

I Patient 1 was notified on 1/4/1 2 at 4:07pm that her medical information had been disclosed to unauthorized Individuals. This notification occurred 15 days after the five day reporting

I period had expit'ed on 12/20/11 .

_fcensing and Certification DIVfsfon STATE FORM

I

10 PHEFIX

TAG

A 021

I

r>r~OVIDI::R'S PLAN OF COR~Ec·noN {EACH CORRECTIVE ACT10N SHOUt D BE

CROSS-REFERENCED TO Tl iE APPROPRIATE DETICIENCY)

, 1 1 11-.J\..Jv

(Xii) Ct:>MPLETE

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9S =OI HV 1-A\'HZIOZ

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