UNIVERSITY OF CALIFORNIA SAN FRANCISCO MEDICAL CENTER

Report ID: 6CDF11.02, California Department of Public Health

Reported Entity: UCSF MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to notify the patient of the breach of her medical information within the required five business days after discovery.Findings:In an interview on 4/5/12 at 2:30 p.m., the manager of licensure and certification (Staff A) stated that on 1/31/12 the facility learned that Patient 1's referral form was mailed to an incorrect address and opened by the person who received it. Staff A said Patient 1 was notified of the breach of her medical information by letter on 2/22/12. Staff A stated the delay occurred due to a changeover in the electronic voice mail system, the manager was not trained to look at messages and the message notifying the facility of the medical information breach was not retrieved in a timely manner.Patient 1's referral form that was mailed to the incorrect address on 1/31/12 was reviewed. The referral form included Patient 1's name, date of birth, medical record number, diagnoses and pre-surgical scheduling information. Review of the report to the California Department of Public Health (CDPH) faxed on 2/23/12, included a copy of the letter sent by the facility to Patient 1 which was dated 2/22/12. The notification to Patient 1 of the medical information breach occurred fifteen business days after the discovery of the breach rather than the five business days required by the regulations.

Outcome:

Deficiency cited by the California Department of Public Health: Medical Breach

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: 6CDF11.01

1 other violation reported on the same date. Note that other citations may be about the same event: 1JNV11.01