C.W. Bill Young VA Medical Center

Report ID: PSETS0000115798, U.S. Department of Veterans Affairs

Reported Entity: BAY PINES FL - 516

Issue:

As required, the Privacy Officer (PO) conducted the third party/authorization audit for quarter one. On 12/29/14, only 13 of 60 authorizations were located in DocSearch. The authorizations unable to be located were requested from the Business Office by close of business (COB) 01/02/15. Authorizations were not provided as requested. The Business Office was asked to meet with the PO weekly to address the authorization concerns. On 01/07/15, the Business Office requested a subsequent audit be conducted after all authorizations were provided for accurate audit findings to be obtained. The PO agreed to conduct a courtesy audit after all authorizations were available. On 01/14/15, the Business Office notified the PO that all authorizations had been scanned and were available. On 01/24/15, the PO attempted to conduct the audit, however only 34 of 60 authorizations were available. The Business Office was notified of these findings. The Business Office requested an extension until after the Privacy Compliance Assurance (PCA) site-visit to provide the 26 authorizations not found. The PCA conducted an assessment of the facility on 02/10/15-02/12/15 and conducted a first party/right of access and third party/authorization audit. Only 12 of 25 authorizations were provided. On 02/17/15, the Business Office requested an extension until COB 02/20/15 to locate the 39 authorizations unable to be located. As of 02/23/15, 6 authorizations have been provided. At this time, 33 authorizations are unaccounted for. The Business Office is currently trying to locate these documents.

Outcome:

02/24/15: PO update -- Fourteen authorizations were found and accounted for. The Business Office will continue to look for the nineteen authorizations still unaccounted for. The Privacy Office requested Surgery Service conduct another sweep of their new space and old space. The boxes were not found. The Surgery Service employee that reported the boxes missing was contacted for further information to be obtained. No further information was acquired. Logistics will conduct a reconciliation audit of their current inventory (approximately 800 boxes) with their data base to verify each box in their custody. It is estimated this will take up to 30 days to complete. 03/02/15: PO update -- Awaiting further authorizations to be located. 03/26/15 PO update -- As of today, twelve authorizations are still unaccounted for. The Privacy Office is requesting that the VA-NSOC determine if there is a need for notification. The Business Office does not feel as though they are missing however, we need to proceed with resolving this event. 03/26/15: The Incident Resolution Service Team has determined that twelve Veterans will be sent letters offering credit protection services.