VA Mid South Healthcare Network (VISN 9)

Issue: On Thursday, 04/25/13, at 9:00 AM, the Program Assistant, Compliance Office (Nashville Campus) found a Gains and Losses (G&L) sheet in the mens restroom (B-111). The G&L sheet contained the full name, last four digits of the SSN, and ward…

Outcome: It is believed the G&L sheets were inadvertently left in the staff restrooms by an employee(s) who attended the morning meeting. HIPAA notification letters were mailed today. Staff have been reminded of the importance of safeguarding patient information to include…

Issue: Veteran A reported that he had received a package containing Veteran B's medication. Update: 04/26/13:Veteran B will be sent a notification letter.05/22/13:This was determined to be non-HITECH reportable by VHA Privacy Office.…

Outcome: Employees reminded to be more cautious when handling documents with PII.

Issue: On 04/24/13, Veteran A was seen in the Emergency Room (ER), Nashville Campus, and referred to the Mental Health (MH) clinic as a walk-in. Upon arrival in MH, Veteran A noticed the ER had given him a wristband which belonged…

Outcome: 5/8/13 - PO found: The Clerk, ER, did not check for accuracy before issuing the wristband to Veteran A. Appropriate action will be taken to include re-educating the clerk on the importance of checking documents for accuracy before issuing. HIPAA…

Issue: The Clerk, Dermatology Clinic (Nashville Campus) notified the Privacy Officer (PO) (Nashville Campus) of the following incident: On 04/24/13, Veteran A checked into Dermatology clinic with a routing slip given to her by the Orthopedic Injection Clinic (Nashville Campus). Upon…

Outcome: 5/6/13 - PO found incident was due to a human error. Clerk has been educated on the importance of checking documents for accuracy before providing to a Veteran.CM letter mailed. PO requests ticket be closed.…

Issue: A clerk faxed a report to a physicians office on 03/13/13. Today, a call was received from an insurance agency, stating that they had received records from this facility and did not know what claim they were for. It was…

Outcome: Staff reminded to verify Fax numbers; however, it appears that the physician's office was at least partially responsible for this one.

Issue: Two patients contacted our CBOC to notify us that one of them had received a form that belonged to the other. We cannot be certain of the details as we are only told the form was only partially filled in…

Outcome: Employees reminded to use caution when handling documents with PII.

Issue: A Non-veteran called and reported that for some reason this VA facility sent medications addressed to a Veteran to their residence. The caller stated that they do not know this Veteran and the Veteran does not live at that address…

Outcome: PO was unable to determine whether address was provided incorrectly or was an entry error by the Clerical staff. Staff are already aware about the importance of accurate entries. HIPAA letter mailed this date and redacted copy uploaded. Request this…

Issue: On 4/18/13 a local County Sheriff's officer attempted to serve a garnishment for VA employee to the VA Police Services. VA Police Officer took the serving Sheriffs Officer directly to the employees supervisor. The supervisor signed to receive the garnishment.…

Outcome: Chief, Fiscal Service and Chief Police Service discussed procedure as defined in our Local MCM. Chief Police Service reviewed the policy again during their service meeting. Supervisor completed the task as she thought best in notifying Fiscal and the employee.…

Issue: Two Veterans' appointment letters containing another Veteran's full name, mailing address and date, time and location of the upcoming appointment were mailed in the same envelope. (This makes three similar issues in the past week.) Update: 04/17/13:The two Veterans will…

Outcome: Document was returned to the Knoxville CBOC. All services were reminded to insure and inspect that only one Veteran's information goes in one envelope.…

Issue: Veteran A received Veteran B's lab results letter. The information contained in the document was: full name, full address, last 4 of SSN, and lab results. This was outside of VA control more than 72 hours and involved one Veteran…

Outcome: Staff has been re-educated on the proper handling of Protected Health Information (PHI).