ST. HELENA HOSPITAL CENTER FOR BEHAVIORAL HEALTH

Report ID: JJ3Y11, California Department of Public Health

Reported Entity: ST. HELENA HOSPITAL CENTER FOR BEHAVIORAL HEALTH

Issue:

Based on interview and document review, the facility failed to safeguard personal medical information for one patient (Patient 1), when copies of Patient 1's forms and personal belongings, were included in the discharge packet for another patient. This failure resulted in possible unlawful and unauthorized use of information and was a violation of the patient's right to privacy. Findings:During an interview on 8/18/14 at 11:25 a.m., Administrative Staff A stated she became aware of the breach of confidentiality of (Patient 1) on 7/29/14, and informed the Department on 8/1/14. This incident was reported within five business days of detection. Record review of Patient 1's record at 2 p.m., on 8/18/14, indicated Patient 1's 5150 record of advisement, notice of certification state form, 5250 advisement, conditions of registration, meds/valuables disposition, and belongings, were included in another patient's discharge packet. During an interview with Administrative Staff B on 8/18/14 at 10:30 a.m., she stated that there were several discharges on the date of the incident. Administrative Staff B also stated that discharges were usually planned, and this discharge was unplanned and was done in a, "hurry." Administrative Staff B stated that no changes in the facility's process had occurred since the breach. A letter was mailed to the Patient 1 on 8/1/14, informing her of the breach.Record review of the facility's policy titled, "HIPAA-Confidentiality of Protected Health Information," dated 8/29/13, indicated, "It is the policy of Adventist Health to maintain confidentiality for patients and employees at all time and under all circumstances."

Outcome:

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