--

1llf ORNIA 111AL 111 ND I IUMN SUVICES l FNCY

1)1PRTMFNT OF lUBLIC HFlTI I

S ff IEMEN r Ot DffHJEN11fs IX1) lROVIDEtllSIJlll1HiCLI ~1) MUI I lPLE CUNS 111JC rlltJN J) ~ fE SlRVlt ND lLNI ltJImiddot cu1lt1ltEC I ION ltJEN I IFICfll)N fJIJMBfHmiddot

--rXCOMPLEfUl

A BIii DINlJ ------------050150

1------------------------~------_________________________ H IJ1NG

--------101212011

NNVH 01 fHOIJFH Ot~ SUPfll lt--H S llltH f MlllRlcSi Cl I Y ~ r1 ff LIP CODE

Sierra Novada Memorial flospital 155 Glasson Way Grass Valrey CA 95945-5723 NEVJDA COUNTY

1--------------middot------------------middot-------------------------------~----~ (X~i ID SIIMMARY S fA fEMENT OF DI FICIENCIES

PHt-FIX (11CH DEFICIENCY MUS f BE PR[CEEOED BY FULL 1

fG iltLGlllA fORY ltlR LSC IDENTIFYING INFORMAflON)

nie following reflects t11e findings of the Depariment of Public Health during a cornplaintbreact1 event visit

Complaint Intake Nurnber CA00282653 - Substantiated

Hepresenting the Oepirtment of Public Health Surveyor ID 26611 HFEN

rile inspection was limited to the specific facility event investigated and does not represent the findings of a full mspection of the facility

Health and Safety Code Section 128015(a) A

clinic health facility home health agency or hospice licensed pursuant to Section 1204 150 1725 or 1745 shall prevent unlawful or unauthorized access to and use or disclosure cJf

patients medical information as defined 111 subdivision (g) of Section 5605 of the Civil Code and consistent with Section 130203 The department after 1nvostigat1on may ass)SS an administrative penalty for a v1olat1on of this section of up to twenty-five thousand dollars ($25000) per patient whose medical information was unlawfully or without authorfzation accessed used or disclosed and up to seventeen thousand five i1uncired dollars ($11500) per subsequent occurrence of unlawful or unauthorized access use or disclosure of that patients medical information

for purposes of the 1nvesti(Jat1on the department shall consider the clinics l1ealth facilitys agencys or hospices history of compliance with

I Ill

p~~~t II lROVlllcHS flN ltgtf 1tJHREC IIUN (XS)

EACH Cltl11HcC 11llmiddot IC I lrJN SI lOULO BE CROSSmiddot COMPI urR~fflll-NCHl I U I HI ~PPlltOPHIAI [ (J[lICl[NCY) 1)lfl

I

Thl SilI rn Nlvada lvkmorial Hnpital (llJ2211

(SNMll1 Mldiral Exlltlllh (i1111111illll1lt lllld tlw rlportabk prilaly hrlmiddotaih

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lkn1 wa Llll to Ph) ilmiddotia11 B I rom lhlmiddot mn1 111t lull 111 S1all rlquirinmicro lltyician B lo

c11111plll thl Pri 1middotacy and Dala Sllmiddoturity

training hy I ktlt lwr 7 2011

vkm11 11a slnt t SNl111 C0

llntrallltd )ltJ22111

Pliv1middotia11 fro111 thmiddot ( hilI or tlw ivktlicalStart rcqui1i11micro middotmpktion ol the 2011 Pnvamiddoty and Data Sllllltly t1aining by

I )llclllhlI I 20 I l

Mcmiddotnu1 va lllt llbull all Medical Stan llllt 7 I kn1hcmiddotr ln1111 lhLmiddot ChilI ol ll1Lmiddot ikd1lmiddotal t1II tlmiddotgmlilll lhlmiddot rnpon1hili1y ol lhmiddot

phv1Llltill~ lo protllI pat1middotll i11furma1w11 wlmiddoturdinmicro lll I kallh Saki) ( middotudcmiddot imiddotv1i11n ~X015 and I 021H

lhy1middot1a11 B n1111pklcd lhl 111 acmiddotgt and IWll11

I gtala Slmiddotmiddotu1 ii) liai11ing

lnlical Staff llial) and Data nmiddot111il 12llI

1r1in111) lmiddott1111pktld

tllrnd u)111plct1tgtt1 11 lhLmiddot Dig1111- lkalth 1111 aLmiddoty and I lata Slnll ii Rcf1middotkr 11a111inmicro i rmiddotqumd forconl1Lmiddot1cdpllvilmiddot1a11 h ifa~ 1middot nl cmiddotadi )iar

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vent IDmiddotOQ0711 61282013 10A4 30AM

LAU ORA r()RY DRfC fORS OR lf~ltlVIDlWSUPPLllR REPHfSEN f A fllES SIGN fJRE flflE (X6) DAT I j J

i

Gy s1ynlngth1s document --HH acknowedg111y receipt of the entire c1tatmn packet f~1 tiuu 4

Any defa1ency s-taternent enJng wiH1 -Hi asertsk (bull) denotes a deficiency which Hie inshtution may br txlttJsed froin correclnfJ providing it is determined

that othr sfeyuaros provide sutfoent protection ta l11i patents Except for nursinltJ homes the ftndinys above are discosable JO days folluwltng the dat3

or su1vrl-y whettier or nut a piJn of correct1on 1s provided For nursmg l1crnes u-bulle above tindmgs and plans of coirection arbull 1118cla$dbi1 14 11ays followug

th~ date the~~ Uocuments ire mwJe Jv-Jdt1Hf~ tu tl1e fac11ity f ijencencies are cited dn amicroproved plrrn uf cmrettion s requisite to c-0ntu1ud program

pa1hctpahon

CALIFORN1A HEAL rtl AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEAL TH

STATEMENT OF DEFICIENCIES (Xl) PROVIOERISUPPllERICLIA (X2) MUI TIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IOENTIFICArlON NUMBER COMPLETED

A BUlOING

060150 8 WING 101212011

NAME Of PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE

Sierra Nevada Memorial Hospital 156 Glasson Way Grass Valley CA 95945-6723 NEVADA COUNTY

(X4)10 SUMMAHY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUS r BE PRECEEDED BY FULL

TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

this section and other related state and federal statutes and regulations the extent to which the racillty detected violations and took preventative action to immediately correct and prevent past violations from recurring and factors outside its control that restricted the facilitys ability to comply wilh this section The department shall have run discretion to consider all factors when determining the amount of an administrative penalty pursuant to this section

A001 Informed Medical Breach

Health and Safety Code Section 128015 (b)(2) A clinic health facility agency or hospice shall also report any unlawful or unauthorized access to or use or disclosure of a patients medical information to the affected patient or the patients representative at the last known address no later than five business days after the unlawful or unauthorized access use or disclosure has been

1

detected by the clinic health facility agency or hospice

I The CDPH verified that the facility Informed the affected patient(s) or the patients representative(s) or the unlawful or unauthorized access use or disclosure of the patients medical information

Based on interview and record review the facility railed to ensure that Patient 1s medical information was kept confidential This failure affected Patient

1s right to confidentiality and could result in unintended adverse consequences for Patient 1

ID PROVIDERS PLAN OF CORRECTION (XS) PREFIX (EACH CORRECflVE ACTION SHOULD BE CROSSshy COMPLETE

TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

Medical Staff Members are responsible to abide by Medical Staff Bylaws Rules and Regulations and all other lawful standards policies rules of the Medical Staff as well as middot those Hospital policies required by state or federal law or by the standards of national accrediting organizations such as Joint Corrunission (or equivalent at the discretion of the Medical Executive Committee)

SNMH Medical Staff Bylaws include routine monitoring and evaluation and corrective action to be taken for physicians The Medical Executive Committee and peer review committees are responsible for carrying out delegated review and quality management functions They may counsel educate issue letters of warning or censure or institute retrospective or concurrent monitoring in the course ofcarrying out their duties without initiating formal corrective action Comments suggestions and warnings may be issued orally or in writing The Practitioner shall be given an opportunity to meet with the Medical Executive Corrunittee or the peer review committee Any informal actions monitoring or counseling shall be documented in the Practitioners file

Medical Executive Committee approval is not required for such actions although the actions shall be reported to the MEC

I

I

I 6282013 104430AMEvent 1DOQ0711

Page ZoHStale-2587

__ _

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155 Glasson Ww Grnss Valley Cl 959bull5-S23 NVADA COUN rvHurra Nevada Metllorial Hospital

------------------------1-------r------middot-- middotmiddotmiddotl l middot--~-shy1-l) ID I $JflMAHY r1fU1tNf Uf lU-IClNCIES PlEFIXJ t 1111 one1fN1Y MIJSf AE PR(Cl [010 13Y FULL

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On 91311 the ticilitys metlical staff rules and

rog11l1tio11s dated iii 1111 middotf wcro reviewed Ihe

rules and regulations read undr-r t1111 section titled ModicJI Staff and Allied Healtil Professionii (NIP) Code of Conduct that P-actitione1s and HPs I

1 shall maintain confidentiality of patient crire

IIinfamwlinn where physically possible in d 111dt111er

consistent with tt1e HIP (Healtll Insurance

I Portab11ily c111rl ccountc1hifity Act) -md state law

middotdd~udegCode of

J Ett11rnf llehavor dalml 41271 middotf indicated that

pt1ysicians were not tu sharP patient 111forn1atio11 in

an una11t11orized manner

On 81311 at 2 50 pill At1111i111stralive (dm111) Stiff C was cisked how physicians are trained on t11e

privacy and conf1dentwlity of patients medical 1I information Ad111in Starr C stated tho medical executive _cornnittee t1au recently _implemented

Irequired nut not mandatory education Admin

I Staff C was unable to explain what that term

Iactually 111eant Admin Staff C conhnned tliat MO 8 was sent the tra1111ng on c011f1dent1altty but the acknowledgernent of traininJ had not been returned ito her office idn11n Stdff C further stated that the 111cdicil stiff was expected to follow the scinie rules

i of confidentiality as the t1ospital employees

on 1020111at 230pm Aunin Staff cIacknowledged tlrnt Patient 1s right to pnvary of l1is 1 med1ccil info11nation was violated

111 lRltlVlntmiddotfS lAN or oRRECTION (tCH 01mlCl IVmiddot A IJM $HOULl lllc 11 w ~s - I 11JMlt I IE

llHHlHl

s~hcs lt fO f ll 1111 APPHI WRl[T ff lI N Y)

MltticI ~~~~_____ lomply with hospital reporting nquire~t~ I through many (but not all) of the same J

imechanisms beiause the I

Medical Slaff Bylaw~ whieh govern their j ibehaviur require compliance with lhL~ i

llluspital policies SNMH ntunitors privacy breaches aml reports compliamc trends and audit results which are suh111ittcLl mo11thy tu itht Eurntive Council aml SNMH

iLeadership meerings for review

lRfHlt

JAG

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