Sierra Pacific Network (VISN 21)

Issue: A Clinical Research Assistant alerted Privacy on March 26, 2013 to findings from a 2010 VA audit. Twelve original informed consent forms and HIPAA authorization forms were discovered missing. Copies were scanned into the Medical Record, so the information was…

Outcome: Privacy has provided credit monitoring letters to applicable parties, and next-of-kin notification to the NOK of deceased participants. Privacy is providing HIPAA and Privacy training to research staff.…

Issue: Veteran A submitted a request for his medical records. When the information was received, Veteran B's information was also disclosed. The information at risk included Veteran B's name, phone number , date of birth and partial SSN. Update: 03/14/13:Veteran B…

Outcome: PO educated ROI clerk, letter sent to Veteran, request ticket to be closed.

Issue: Veteran alleged he was meeting with a male CBOC employee, and that a SW took the male employee into another office and audibly "blurted out he was not to be seen alone by a female." The Veteran alleged a CBOC…

Outcome: 1. Subject of the complaint completed TMS Privacy & Information Security & Rules of Behavior (refresher) training.2. All staff reminded of auditory safeguard responsibilities.3. Appropriate disciplinary action taken.…

Issue: While attending therapy, a Veteran completed a "PCL-M" checklist. Per the psychology intern who reported the incident, it is a checklist used to identify problems and complaints that Veterans sometimes have in response to stressful military experience. The checklist does…

Outcome: 1. The psychology intern received retraining (TMS VA Privacy and Information Security and Rules of Behavior) on 2/14/132. In the future, she will scan the group visit room to ensure all documents have been retrieved. 3. HIPAA notification letter mailed…

Issue: A San Francisco VAMC employee used a window envelope to mail information to a Patient. Visible through the envelope's window was a label containing the Patient's last and first name, full SSN, and date of birth. Update: 03/04/13:Patient B will…

Outcome: All employee training will be provided reminding staff of proper procedures to follow when internally as well as externally mailing III/PHI.

Issue: A San Francisco VAMC pharmacist inadvertently faxed a request for medication administration record to the wrong number. The recipient notified SFVAMC of the mis-fax in less than 1.5 hours of receipt. Per the pharmacist, the unintended recipient was asked to…

Outcome: 1. Unintended recipient properly disposed of the mis-faxed information2. Sender completed training3. Credit monitoring offered to the patient4. Disciplinary action is not required/applicable…

Issue: A non-VA Care (Fee) authorization was mailed to a Patient. Visible through the mailing envelope window was the medical conditions for which service was authorized. The Fee Manager was notified of the incident, and instructed staff to use the system…

Outcome: 1. All Non-VA care staff completed focused training.2. Fee authorizations are now mailed with a cover letters 3. HIPAA notification letter mailed…

Issue: A Veteran was transferred to a local Non-VA Health Care facility on 2/12/13, and a packet of his medical records were sent with the patient. At the receiving facility the staff found a list that contained 22 patients full name…

Outcome: Provided education to the staff in Urgent Care to ensure they are only sending the correct patients information during transfer and encouraged them to stop printing this report.

Issue: Wage and Tax statements W-2s for approximately 50 employees have been reported missing by Fiscal Service. W-2's were placed in the mailroom addressed to a specific person and department on 01/31/13. On 02/4/13 an employee reported that there were no…

Outcome: Fiscal service updated their policy to include how W2s will be distributed in the future, provided training to all timekeepers on the process to provide the W2s to staff, W2s cannot no longer can be sent via intra office emails.…

Issue: A Veteran received a copy of another Veteran's medical records from an outside provider contained in the VA system of records. No SSN was on documents. The name, DOB, address and medical history was on documents Update: 02/13/13:Veteran A parts…

Outcome: Credit monitoring letter sent, employee educated, request ticket to be closed.