Sierra Pacific Network (VISN 21)

Issue: A VA OIG Hotline Case was referred to the facility for response to various allegations. A Veteran reports that a VA employee with whom Veteran shared a home, left other Veterans' medical records/treatment notes in the home when the VA…

Outcome: Employee is be presented with a Proposal for Termination letter from HRMS inconjuction with other factors surrounding this event.

Issue: A blood draw employee reported someone taking a Veterans ID card and laboratory labels from the blood draw room. In addition, when the Veteran went to collect his travel pay, it was picked up by someone else who was using…

Outcome: Notification sent to the patient. Veteran's ID cards and printed laboratory labels were relocated to a secured location away from patients.…

Issue: A clerk received a notification letter from UPS, stating that the records for one Veteran were lost or damaged. Update: 01/24/12:The Veteran will be sent a letter offering credit protection services, as his SSN and medical information were disclosed inappropriately.…

Outcome: Not VA fault.

Issue: The Chief of Staff brought a high school student to morning report, where patient information was being discussed, to include SSN, diagnosis, treatment and follow up. Update: 01/09/12:The ten patients will receive a letter offering credit protection services.02/28/12:An appeal was…

Outcome: Education and training was provided and appropriate action taken

Issue: Former VHA employee alleges that several VHA employees accessed his medical records without permission. report was made to OIG Update: 03/12/12:The former employee will be offered credit protection services has is SSN was accessed inappropriately.…

Outcome: Privacy Officer conducted further investigation, found one VA employee improperly accessed Veterans vista screen (Change Patient Screen), could not find that any PHI had been accessed. Forwarded to HR for appropriate action.

Issue: A patient, who is also an employee, states that he requested his medical records to be released to his non-VA health care provider on 10/25/11. He also reports that his non-VA health care provider never received his medical records that…

Outcome: The missing information was transmitted through the US Mail System and was not caused by fault of our staff.

Issue: While State Investigators from a State Licensing Board were investigating a complaint against a Registered Nurse (RN) employed at this facility, they disclosed to the facility Privacy Officer (PO) that the complainant had included copies of the RN's employee medical…

Outcome: A Sensitive Patient Access Report is routinely reviewed by the ISO and PO to identify potential unauthorized access to medical records. An employee that was identified in SPE 000000053261 as having accessed this record was disciplined at that time, we…

Issue: A letter to Veteran A was mis-labeled with information that should have been placed on another form. The inappropriately used mailing label contained Veteran B's name, SSN, and DOB. Update: 12/07/11:Veteran B will be sent a letter offering credit protection…

Outcome: We have taken corrective measures by making the responsible party re-accomplish their privacy, security, and office specific training.

Issue: Veteran A received a medication reconciliation of Veteran B with his medication reconciliation in the mail. The medication reconciliation contains the name, mailing address and list of medications for the Veteran. Veteran A returned the medication reconciliation back to the…

Outcome: Pharmacy staff will double check mailings before stuffing envelopes.

Issue: Boxed up records were given to UPS to deliver to San Diego office for evaluation of Veteran files for benefits compensation. The package never made it to the destination and wasn't discovered until one of the Veteran's inquired about their…

Outcome: We have initiated an investigative search with UPS for the recovery of these files. Have also sent affected Veterans credit monitoring letters. Request closure of this ticket.…