UNIVERSITY OF CALIFORNIA SAN FRANCISCO MEDICAL CENTER

Report ID: 6CDF11.01, California Department of Public Health

Reported Entity: UCSF MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to notify the California Department of Public Health (CDPH) of the breach of personal health 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 and CDPH was notified on 2/23/12. 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 (CDPH) notifying them of the breach of Patient 1's personal health information indicated it was faxed on 2/23/12. The facility was 16 days late in reporting the medical information breach to CDPH.

Outcome:

Deficiency cited by the California Department of Public Health: Health & Safety Code 1280

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: 6CDF11.02

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