Transcription
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CUAIDENTIFICATION NUMBERCONSTRUCTIONA050056(X3) DATE SURVEYCOMPLETED13.JIH, -1B WING02/17/2012NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CIT'I'. STATE. ZIP CODEAntelope Valley Hospital1600 W Avenue J, Lancaster, CA 93534-2814 LOS ANGELES COUNTY{X4)1DPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)(X5)COMPLETEDATE!The following reflects the findings of the,Department of Public Health during afomplaint/breach event visit:fr .bomplaint Intake Number:A00222831 - Substantiatedrt···!Representing the Department of Public Health:Surveyor ID# 15727, REHS, HFE I- ·,.'.,.-:.::The inspection was limited to the specific facilityevent investigated and does not represent the ndings of a full inspection of the facility.C::)I'I ealth inic,and Safety Code Section 1280.15(a) Ahealth facility, home health agency, or. ospice licensedpursuant toSection 1204,11250, 1725, or 1745 shall prevent unlawful orunauthorized access to, and useor disclosurepf, patients' medical information, as defined insubdivision(g) of Section 56.05 ofthe CivilCode and consistent with Section 130203. Thedepartment,after investigation, may assess anadministrative penalty fora violation of thissectionof up to twenty-five thousand dollars{ 25,000)perpatientwhosemedical nformationwasunlawfullyorwithout uthorizationaccessed,used, ordisclosed,,andup to seventeen thousand five hundred, ollars ( 17,500)per subsequent occurrence f unlawful orunauthorized access,use, or. isclosure of that patients' medical information.A.i1·1·B.c.Ilr,1s,10At the time of the occurrence, thepolicy was reviewed by both NurseiLeaders and Human Resourcerepresentatives. No changes were felt!to be needed to the policy.,Verification that staff received'instructions and signed aconfidentiality agreement on12/17/2009 was also made. Thepolicy violation resulted in terminationof the employee initially 3/29/10,f/29/2010followed by further investigation,reinstatement, and upon confirmationifinal termination was effective5/4/2010.F'4/2010Privacy Officer, Director of HealthInformation and Medical Records.Monitoring for compliance withregulations, and hospital privacypractices, occurs through a variety of Imethods:- Auditory monitoring for verbalIbreach on a continuous basis.IIIeasedon interview andrecord review, thefacilityfailedtopreventunauthorized isclosure of Patient 1's medical information toIEvent ID:DR75111/6/2016LABORATORY DIRECTOR'S OR PROVIOER/SUPPldER'E. -LP/By signing this document, I am acknowledging receipt10:07:05AMTITLE,Jf lh,eentire citation packe); Pagets/. 1 thru 5Any deficiency statement ending with an asterisk (·) dli! afes a deficiency which t e institution may be excused from correcting providing it isdetermined that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 daysfollowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction aredisdosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction Isrequisite to continued program participation.State-2567age o
CALIFORNIA HEAL1H AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEAL1HSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:CONSTRUCTIONA050056B.W\G- ------------1------------(X3) DATE SURVEYCOMPLETEDB WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODEAntelope Valley Hospital1600 W Avenue J, Lancaster, CA 93534-2814 LOS ANGELES COUNTYSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)(X4)1DPREFIXTAGmaintainthe confidentialityandprivacy ofPatient 1. Staff A disclosed Patient 1's surgicallorocedure and diagnosisto a familyfriendrithout Patient 1's authorization to do so.\Findings:hn September 20, 2010,an unannounced visit as conducted at the facility to investigate an' ntityreportedincident regardingStaffA!disclosed Patient 1'smedical nappropriately, ecord information to a family friend.!an interview onSeptember 20, 2011, atlouring12:25 p.m., Staff B(vice president for nursing)lstatedthe facility's investigation revealed thatStaff A called a family friendof Patient 1 tonformher of thediagnosis andprocedure!done on Patient 1. The family friend in turn!called the husband of Patient1. The husband 'ofPatient1 theninformedhospitalmanagement that he received a telephone callirom the family friend about Patient 1's medical'nformation being disclosed to Staff A.IDPREFIXTAG02/17/2012PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)(XS)COMPLETEDATEreontinued from page 1- Expectation was and is in place andcommunicated to all staff annually,that any suspected privacy breach isreported to the privacy officer.- Patient Grievance process from whichwe would identify any potentiallysuspected breach reported bypatient(s).- Privacy Officer Notification process- .,calls or e-mails made to the Privacyofficer of any suspected breach.calls received from any source areaddressed accordingly.- Periodic audits of electronic recordsor other system sources adoptedbeginning 2011./15/10D. Corrective actions were taken at the/29/10time of the occurrence. /4/20101·1·I reviewof themedicalrecord(Patientegistration/AdmissionForm) revealedPatientwasadmitted to the facility on March 15, 010,with thediagnosisof an incompetent ervix (weak cervix).!ir,review perativediagnosisbulgingEvent ID:DR7511State-2567of the physician's post procedure/postnotesrevealedthepre-op/post-opwas 6/201610:07:05AMageo
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDePARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X 1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:CONSTRUCTIONA050056(X3) DATE SURVEYCOMPLETEDB.ll1 - --------- -tB WING--------------1NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS. CITY, STATE, ZIP CODEAntelope Valley Hospital1600 W Avenue J, Lancaster, CA 93534-2814 LOS ANGELES COUNTY(X4)1DPREFIXTAGIiiIDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)02/17/2012(XS)COMPLETEDATEPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)!!jamniotic membranes with umbilical cord bulgingliintothe vagina occupying the entire vaginalvault. The cervixwas 2-3 centimeters dilated,i and 50% effaced. The procedure performed ascervicalcerclage-attemptof placement\(the cervix is sewn closed during pregnancy).I,A review of the report of operationime Out) dated March 15,rsStaffA was the scrub technician.I2010,(Part A andrevealedIAreview ofafacility document(Privacy!Complaint Investigation) dated March 17, 2010.:IrevealedPatient1 statedherhusband!received a telephone call from a family petentcervixandhad tohave acerclage done." The husbandasked how didthey know thisinformation, andtheir friendinformed her husband that Staff A had calledher.Patient 1 stated they were overwhelmed,did not havethe opportunity toinform,andfamily members and friends thatthey wouldhave wanted to inform them on their own.The."II'report also revealed that Patient 1 stated,.have a lot to deal with and don't need thisat his time. I just want to concentrate on myselfrnd my baby to get out of these both alive."I1·jAreview of an e-mail sent by Patient1's·, husband to thefacility'semployee and laborrelationsmanagerdatedApril 28,2010,! indicatedthe reasonPatient 1 aseofconfidentialIIiEvent 1D:DR7511State-25671/6/201610:07:0SAMageo5
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION ----------(X3) DATE SURVEYCOMPLETEDWINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS. CITY. STATE. ZIP CODEAntelope Valley Hospital1600 W Avenue J, Lancaster, CA 93534-2814 LOS ANGELES COUNTYSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING OVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)(XS)COMPLETEDATE. nformation was that they felt what they wereoing through at the time was very sensitive nd traumatic.treview of the personnel filefor Staff AmdicatedStaffAcompletedthe2009 Annual1Regulatory Review onFebruary10, and Accountability Act), and HIPAAConfidentiality.StaffA alsosigneda17.confidentiality agreement datedDecember12009, which states, "Violation of this agreementaction, including ;may be cause for disciplinaryremoval from the respective ermination, and/orposition of representation with the hospital".IIreview of the Notice of Intended TerminationndRight to Respond dated March 22,2010evealed Staff A was notified that the Hospitalntended to terminate her employment effectiveMarch29, 2010.Staff A signed the document1jon March 22, 2010.'!i!Thefacility'spolicyand procedureon/confidentialitystipulatedconfidential nformation may not be disclosed or divulged to hird parties. All employees whohave access to)nformationpertinenttopatients,other mployees, or organizational operations, whichprohibited,s of a confidential nature, shall be romdiscussing or revealing such information n any unauthorized manner.IlBased/.Health.on the foregoing,the facility violatedandSafety Code section 1280.15(a) byiEvent ID:DR7511State-25671/6!.201610:07:0SAMage 4 o
CALIFORNJA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PL.AN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:(X3) DATE SURVEYCOMPLETEDCONSTRUCTIONA a.u:K,B WING050056----------------1--------------!NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODEAntelope Valley Hospital1600 W Avenue J, Lancaster, CA 93534-2814 LOS ANGELES COUNTYIIi(X4) IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)IIIDPREFIXTAGI02/1712012'PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)It(X5JCOMPLETEDATEIIIitsfailure to prevent unlawful or unauthorizedaccess to, and use or disclosure of a patient'sredical information to a family friend without Iirhe patient's authorization.IIi!III;Event 1D:DR7511State-25671/6/201610:07:0SAMageo 5
Antelope Valley Hospital 1600 W Avenue J, Lancaster, CA 93534-2814 LOS ANGELES COUNTY . For nursing homes, the above findings and plans of correction are . If deficiencies are cited, an approved plan of correction Is requisite to continued program participation. age . o . State-2567 -----CALIFORNIA HEAL1H AND HUMAN SERVICES AGENCY
