PR1Nf(O 0312612012 FORr1 iPPROVH)

Cltlliforrna Deoanment o Public Health

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srn[LT AOCRCSS CllY SIA I CODE

FEATHER RIVER HOSPITAL 5974 PENTZ ROAD PARADISE CA 95969

tAl l SUWlARY S IAIHltH 1)f Ol~ 1oNCIES f(j lROVlCR s PLAN or CORRECT~ON I lbull t bull 1 1-~i OFlbullCtrtlCY wsmiddot BE Pil[CtOEO BY FULL lr-tof If l ACI I CORRU 1IVt ~c noI SriOULD lli

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i OOC Initial Comments A 000 One patient whose record was 61511

l he following reflects the findings of the Cali fornia inappropriately accessed was Department of Public Health during the notified by the FRHC 111vesltgaHOn of an entity reported 1nc1den1 Admin istrative Assistant and

the other patient who we were r l1l repolleJ 111c1dent 273375

unable to reach by phone was 1110 111spection wos limited to the spec1f1c entity notified by a certified letter from 61611 reported 1nc1dent 1nvest1ga1ed and does not the Supervisor of Health represent 11e ftldtngs or a ru11111spect1on or the Information Management fac1111y

Heprescnt111g the Department 28650 HftN Health Center (FRHC) staff 52511 were reminded by the Nurse

1Jeftc1erc1es were wnaen fer tllbullly reported Manager to report any 1nc1dtnt273375atA002 A017 A018A 019 suspected privacy breaches to and A 021

their supervisor and FRH Privacy Official using eventt- 1)1)2 Not lntorrned MeltJal Breach i 002 reporting forms so that

Health and Safety Code Section 1280 15 b(2) appropriate action and A cl1111c health facility agency or hospice shall notification can occur also report any unlawful or unautnonzed access to or use or disclosure of a pattents medical

The staff member involved was 52511information to the affected patient er the patients rep1 esental1ve at the last known altjdress no later dismissed from employment than five business days after the unlawful or unaut11onzed access use or disclosure has been The success of ongoing privacyd~tected by the chr1c health fac1hty agency or

protection actions are nosp1ce monitored by the event

11 e CDPH verified tllal the facility fabullled lll inform reporting system Any reports tne affected pat1ents) or tle patients of privacy compromise are rpresenaive(s) of the unlawful or unauthonLed reviewed by the FRH Privacy access use or disclosure of the pahents medical

Committee 1n forrnat1on

euroSl NIAPES SIGMIUlltL

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Ca l1forn1a Depacti 1e11 t of Public Healtl

middot T - ~ 1 F~ r 1middot r D 1 iC1t NcH- ~ I 1 1PCJv11 FR1SUbullmiddottL l l R-lt 11r middot X~ l 1middot1 l L li l-l t CONSlf~ Ut T ilt HJ middot tmiddot1 middot r middotl 0 1 ( J-11 c r(I N 11JfNlir lLA 110N f U~tilOk

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c 06222011

sur11 lliY s ro I lMtrJ I ormiddot DfTIC IL NCI) PIWVIU[R S PLAN OF COkh EC I ION 1Jf

1Hl I IK N~ l JfflC IEt~CY 111Js r 81 lRLClJlL) BY cJ I 1cAt~I 10RRECTi1r Alt nm~ SriOUll) o E 1t11l-middotU bullX-t IU 10

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rmiddot- r Imiddot~ lt HUUI I urn Oil l s r ill N I f-Y IN( INr JHr 1 1 0~lt I Cbulllt)SS PFTk[N1Eo r 0 rgt-1 E CPfHOll-i f

LJt tmiddotl t i NCY

00 Con tinued From page

rt11s Statute 1s not me t as evidenced by

1 rJ I 280 15a) l -leal tl1 amp Safety Code 1L 030

1a) f cl111 1c t1ealt l1 faci lity home hea lth agency or hospice licensed pursuan t to Section 1204 1 50 1 7 2~i or 1745 sr1a ll prevent unlawil or u 11iu tr1or1zeci access to and use or disclosure of pat1~nts mcdrcal 1nforn auon as defined 1n su bd 1v1sio11 lg) of Section 56 05 of the C1 11 Code 3 W cons1ste11 t J I h Section 30203 The department after 1nvestigat1on may assess an ad1nr n1strat1ve penalty for a v1o lal1on of this section of up to twenty -five t110usand dolarmiddots ($25 000) per patient whose 111edical 1nformat1011 was unlawfully or w1 t ~1ou t aul11or1zation accessed used or disclosed and up to seven teen thouslt1nd five hundred dol lars ($17 500 ) per subsequent occurrence of un lawful or unau horized access use o r disclosure of that pa tients medical information For purposes o f the 1nves1gation the department st1al l consider t11e clmics health faci litys agencys or hospices history of compliance w ith this section and other re la ted state and federal statutes and regulat ions tt1 e ex tent to which the facility detected violations and took preventative action to 1mrned1ately correct and prevent past viola tions from recurring and fa tors outside its control that res tric ted t11e

fac ilitys ab il ity to comply with t111s section The department sha ll r1ave fu ll discretion to consider ail fac tors when determining the amount of an ac1m1 111 strat1ve penalty pursu ant to tl11s sectr on

rh1s Statute 1s not met as evidenced by

1 002

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~al 1forn1a Department of Public Health

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H v ll~L __ _ _ _ CA230000005

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P- 01 - Conunued From page 2 A 01

Based on 1nterv1ew and record review the ac1il ty failed to safegua rd confident1a health mformat1on or tvJO patients Pa tien ts 1 ancl 2J

011 616l 1 al 4 22 pni t11e Californ ia Depar 1 erll of l)ubl1c Heall CDPH ) received a faxed repoll writ ten by Adm1nistrat1vt fldmin) Stal A w h1c1middot1 indicated t11at the middotac1lrly l1ad 1dent1fied unaut11oriLed access of Pat1enmiddots 1 and 2s persona healt11 1nforrnat1on on 5125111 a 8 L3 am

Dur 1ng an 1ntuv1bull2w or G2211 at 10 2gt am Ad1111n (Adm1n) Staff and Adm1n B stated that Customer Serv ice Represer tauve (CSR ) C t1ad l)een term inate after 1t was determir ied tlla t she -gt

11 ad been inappropriately accessing and viewing = shyI-

portions of Patients 1 and 2s electron ic rned1cal D -middot- _I

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and t1ad accessed multi ple parts of th eir medical - - - 7 ~ t-~

CJ - shy--- Drecords Th is 1nformat1on 1r1cluded middot names gtI0 middotmiddot-middotshyadd resses social security numbers phone o ~ -0 -shynumbers insurance date of appointments 3D emiddot i-i-

nursing notes medications phys1c1ans progress () ~ --notes encoun ter 1s1ts notes and diagnosis lists N ()

CSR C employee file was re iewed A docu ment titled Fea ther Ri er Hospital Conf1dent1ality Ag reement dated and signed by CSR C on 1112003 read It is the policy of Feather R1ve1 Hospital to rna111ta1n confidential 1nformat1on i11 strrct confidence both while at work and off uuty It is aiso the respons1btl ity of any who have contact with confidential 1nforrnat1on to preserve s ich records against loss destruction tarnper111g and 111 appropr1ate access and us Any breach of confidential ity rep resents a fa ilure to meet tt1e legal professional and e h1 ca t standarmiddotds

L1oens111g ano Cert1f1ca11on D1111s1on

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FEATHER RIVER HOSPITAL

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I I() SUI ~ 11RY 3 [ f EMEN I or Olf lCIF NCll s l i~ r 1-i li tCACH DEF ICIENCY MUS I llE fRlCEOllJ lY l ULL

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expected and constitutes a vio lation of this policy A breacl1 need not take the form of a delibera te ci ternp t to viol ate conf1de 11 t1ali ty bu t includes any L nnecessary or unau l1onzed use or disclosure ot co 11 f1dent1al 1nform at1011 - due to ca relessness cu nosrty or co icern or for personal gain or malice 1nc lud111g but r c t res tricted to mformal d iscussion

A document titled Em ployee 0 1sc1pltnary Action l~eport middotdated 5125 11 read On more l1an or e occas ion you (CSR C) l1 ave accessed pro tecteo heal th 111forrnation of your family (Pat10nts 1 and 2) This is a direct rolat10 11 omiddot fac1l 1tys pol1cres You (CSR C Jhave had Il l rn erous train ing regard ing t1e po li cies relat ing to privacy and HIPAA (Heal h Insurance Portabil ity and Accou nta tJ1lity Act J

During a 11 1nterv1ew and document review on 622111 at 1205 pm wrth Ad rn1 11 A CSR Cs computer log reports were reviewed from 1 1 11 th ro ugh 5125111 According to Adm1n A the audit sl1owed t11at there was a pa ttern of excessive inappropri ate anu una thonzed access ing of Patien ts 1 and 2s medical records On 5125111 C SR C was terminated by tl1e facili ty for v1 o law1g the facrl1ty s policy and procedures by accessing her fa r dys protected health 1nformat1on

I he facil1ty failed to preve nt unlawfu l o r una thonzed access to and use or disclosure o f patients rneli 1cal information accord ing to Health and Safety Code Section 1280 15a )

A 018 1280 15t b)( 1) Health amp Safety Code middot12so

(b) (1) A clin ic hea lth faci lity home health agency or hospice to which subd ivision (a) applies shal l report any un lawful or unauthorized

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Ca lifornia Department of Publ ic Health

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3Ccess to or use or disclos ure of a pa t1 e1ts medica l inform ation to tt1e department no la ter t11an five ou-51ness days a fte1 the unlawfu l or unauihonzetJ access use or disclosure has been detected by tl1e cl1 n1c I eaIth fac il ity ome t1ealtl agency or hospice (bJ 12 i Sut iect to subd1v1s1 on (CJ a cl inic heal h fac1li y l1orne health agency or hospice shall also repo1 t any u1law ful or unau t 1onzed access to or use or disclosure ot a pat ient s rned1ca l 11 fonn at1011 lo the affec ted patient or the p31ent s represen ta tive at the las 1-nown add ress no later than five business days after the unlawfmiddotu1or unauthorized access use 01 d isclosure has been de tected by the c lin ic health facltty home healt1 agenly or hospice

l his Stmu tbull~ 1s not met ilS evidenced by

1280 lgt ibi(2) Healt11 Sa fe ty Code 1280

tb) 2 J Subject to suorJ 1v1s1on (c) a clinic t1eal th fac1l 1ty home l1ealth agency or hosp ice snail also report any un lawful or unauthorized access to or use or d isclosure o f a patients med ical 111 form at1on o the a ffec ted pa tient or the patients representative at the last known address no later than five business days after the unlawfu l or unauthorized access use or disc losure has been detected by the cl inic healt l1 faci lity horne health

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Cal1forn1a Deoartment of Public Hea th

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agency or hos p i ce~

fh1s Statute 1s nor n1et as evidenced by Based on 1nterv1ew and record review the ac1hly fa iled to 11 forin two affected patients of middot 11 au thonzed access to their med1c3 1111 format1on 110 later tl1an five b L s1ness days after 1t had IJeen detected w a1ents 1 and 2)

r 1nd111gs

Dunng an 1nte1 1ew 0116221l at 0 25 am Ad1rnn1stra ive (Ad m111) Staff A confi rmed lie follow1ng

Fram 1 11 to gt1 11 Custo1ner Service Representative C 111 appropnately accessed portions of Patients 1 and 2s electronic medical records multiple tunes w1t11out the proper aut11onzat1011 l he fac1il ly became awa re of the unau r1onzed access on 52511 al 823 am

1 ~ a t1ent i v1as notified o tile nau thonzed access on 6115 1 at pill ly tltlepl10ne and t11 e11 by letter on 61 6 11 Pa11en t 2 was not1f1ed of t11amp unauthonzeo access on 6 1611 by letter folio 11119 an unsuccessful telephone atte1 pt

Adm 1n Staff A ltJcknowledged middothat Patients 1 antJ 2 si1ould have been 1middot ot1f1ed by 6121 1 wh1c l1 would have bee11w1tli111 5 bus111ess days rom the 1dent1f1ca t1011 of the 1nauthorized access

The facilny was 14 ca lendar days late 111 report in g the unauthorized access to Patien t 1 and 15 calendar days late in report1119 the Lii autho rized

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Ca l1forn1a Depacti 1e11 t of Public Healtl

middot T - ~ 1 F~ r 1middot r D 1 iC1t NcH- ~ I 1 1PCJv11 FR1SUbullmiddottL l l R-lt 11r middot X~ l 1middot1 l L li l-l t CONSlf~ Ut T ilt HJ middot tmiddot1 middot r middotl 0 1 ( J-11 c r(I N 11JfNlir lLA 110N f U~tilOk

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rmiddot- r Imiddot~ lt HUUI I urn Oil l s r ill N I f-Y IN( INr JHr 1 1 0~lt I Cbulllt)SS PFTk[N1Eo r 0 rgt-1 E CPfHOll-i f

LJt tmiddotl t i NCY

00 Con tinued From page

rt11s Statute 1s not me t as evidenced by

1 rJ I 280 15a) l -leal tl1 amp Safety Code 1L 030

1a) f cl111 1c t1ealt l1 faci lity home hea lth agency or hospice licensed pursuan t to Section 1204 1 50 1 7 2~i or 1745 sr1a ll prevent unlawil or u 11iu tr1or1zeci access to and use or disclosure of pat1~nts mcdrcal 1nforn auon as defined 1n su bd 1v1sio11 lg) of Section 56 05 of the C1 11 Code 3 W cons1ste11 t J I h Section 30203 The department after 1nvestigat1on may assess an ad1nr n1strat1ve penalty for a v1o lal1on of this section of up to twenty -five t110usand dolarmiddots ($25 000) per patient whose 111edical 1nformat1011 was unlawfully or w1 t ~1ou t aul11or1zation accessed used or disclosed and up to seven teen thouslt1nd five hundred dol lars ($17 500 ) per subsequent occurrence of un lawful or unau horized access use o r disclosure of that pa tients medical information For purposes o f the 1nves1gation the department st1al l consider t11e clmics health faci litys agencys or hospices history of compliance w ith this section and other re la ted state and federal statutes and regulat ions tt1 e ex tent to which the facility detected violations and took preventative action to 1mrned1ately correct and prevent past viola tions from recurring and fa tors outside its control that res tric ted t11e

fac ilitys ab il ity to comply with t111s section The department sha ll r1ave fu ll discretion to consider ail fac tors when determining the amount of an ac1m1 111 strat1ve penalty pursu ant to tl11s sectr on

rh1s Statute 1s not met as evidenced by

1 002

A 01

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L1ccns1ng amj Cert1f1cat1on Drv1s1on -- STA1E FORM HH 11

-----

~al 1forn1a Department of Public Health

S l bull- U 1N I O i- l)CC ICf Nmiddot~ lt-S I PHl) Ii 11- HSUPl-LIUVCI 1 middot~ Ml t rIPU CJNS I HUC I UN bull bull I) 1bull11 1 middot CUllt1H t I 1urshy ILgt tN I r It flON Nur Fir R

H v ll~L __ _ _ _ CA230000005

SI RH r 10u Rt$S CITY S I TF llf- C)l)f

5974 PENTZ ROAD FEATHER RIVER HOSPITAL PARADISE CA 95969

P f ~I NTED 0312620 12 f(H~M PPROV[D

x l) I SUlVEY 1~1)MPLt 11 D

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Dff lClf NCY l

P- 01 - Conunued From page 2 A 01

Based on 1nterv1ew and record review the ac1il ty failed to safegua rd confident1a health mformat1on or tvJO patients Pa tien ts 1 ancl 2J

011 616l 1 al 4 22 pni t11e Californ ia Depar 1 erll of l)ubl1c Heall CDPH ) received a faxed repoll writ ten by Adm1nistrat1vt fldmin) Stal A w h1c1middot1 indicated t11at the middotac1lrly l1ad 1dent1fied unaut11oriLed access of Pat1enmiddots 1 and 2s persona healt11 1nforrnat1on on 5125111 a 8 L3 am

Dur 1ng an 1ntuv1bull2w or G2211 at 10 2gt am Ad1111n (Adm1n) Staff and Adm1n B stated that Customer Serv ice Represer tauve (CSR ) C t1ad l)een term inate after 1t was determir ied tlla t she -gt

11 ad been inappropriately accessing and viewing = shyI-

portions of Patients 1 and 2s electron ic rned1cal D -middot- _I

c-) J -shy

records csr~ C was related to Patien ts 1 and 2 bull --)

J 0

and t1ad accessed multi ple parts of th eir medical - - - 7 ~ t-~

CJ - shy--- Drecords Th is 1nformat1on 1r1cluded middot names gtI0 middotmiddot-middotshyadd resses social security numbers phone o ~ -0 -shynumbers insurance date of appointments 3D emiddot i-i-

nursing notes medications phys1c1ans progress () ~ --notes encoun ter 1s1ts notes and diagnosis lists N ()

CSR C employee file was re iewed A docu ment titled Fea ther Ri er Hospital Conf1dent1ality Ag reement dated and signed by CSR C on 1112003 read It is the policy of Feather R1ve1 Hospital to rna111ta1n confidential 1nformat1on i11 strrct confidence both while at work and off uuty It is aiso the respons1btl ity of any who have contact with confidential 1nforrnat1on to preserve s ich records against loss destruction tarnper111g and 111 appropr1ate access and us Any breach of confidential ity rep resents a fa ilure to meet tt1e legal professional and e h1 ca t standarmiddotds

L1oens111g ano Cert1f1ca11on D1111s1on

SfAIE FORM H 1 ~W t

I

-JQ11Q1Jl1a Depa rtment of Put)l1c Health

~gt 11~ I l l N I OF l) E F L ~ J C 1 i $

1 1middot1 lt 11r CORREC1 11J 1

FEATHER RIVER HOSPITAL

1X 11 f f()VlJt RISUPl I If- RICI 1 liJEt l I - 1( I lt)N U iltJ lI

CA230000005

I I() SUI ~ 11RY 3 [ f EMEN I or Olf lCIF NCll s l i~ r 1-i li tCACH DEF ICIENCY MUS I llE fRlCEOllJ lY l ULL

~ -~ -( 1 ( l l A I ORY OR I Sr I Lbull Fr-H ~ Y i N r llltt- U lM1 1 0~

A o 11 Co11 t11ued From page ~

expected and constitutes a vio lation of this policy A breacl1 need not take the form of a delibera te ci ternp t to viol ate conf1de 11 t1ali ty bu t includes any L nnecessary or unau l1onzed use or disclosure ot co 11 f1dent1al 1nform at1011 - due to ca relessness cu nosrty or co icern or for personal gain or malice 1nc lud111g but r c t res tricted to mformal d iscussion

A document titled Em ployee 0 1sc1pltnary Action l~eport middotdated 5125 11 read On more l1an or e occas ion you (CSR C) l1 ave accessed pro tecteo heal th 111forrnation of your family (Pat10nts 1 and 2) This is a direct rolat10 11 omiddot fac1l 1tys pol1cres You (CSR C Jhave had Il l rn erous train ing regard ing t1e po li cies relat ing to privacy and HIPAA (Heal h Insurance Portabil ity and Accou nta tJ1lity Act J

During a 11 1nterv1ew and document review on 622111 at 1205 pm wrth Ad rn1 11 A CSR Cs computer log reports were reviewed from 1 1 11 th ro ugh 5125111 According to Adm1n A the audit sl1owed t11at there was a pa ttern of excessive inappropri ate anu una thonzed access ing of Patien ts 1 and 2s medical records On 5125111 C SR C was terminated by tl1e facili ty for v1 o law1g the facrl1ty s policy and procedures by accessing her fa r dys protected health 1nformat1on

I he facil1ty failed to preve nt unlawfu l o r una thonzed access to and use or disclosure o f patients rneli 1cal information accord ing to Health and Safety Code Section 1280 15a )

A 018 1280 15t b)( 1) Health amp Safety Code middot12so

(b) (1) A clin ic hea lth faci lity home health agency or hospice to which subd ivision (a) applies shal l report any un lawful or unauthorized

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iibull I 1lt11 N bullJ UU middot IL I Cll S J OA r E SUINY ) middot PROlllJl HiSUPPc If RiC IA bullrJI i i - N ( )f bull bull) llfrL 11lt r C lt1M P F l i-l)11bull1 N 111 1c ~ ruiN N1Jr--rn1

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S IHt l AUDRtSS C IY Sfiltll Lii Clt)l lr

5974 PENTZ ROAD FEATHER RIVER HOSPITAL PARADISE CA 95969

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C tJ1 1t1riued Fro rn page 4

3Ccess to or use or disclos ure of a pa t1 e1ts medica l inform ation to tt1e department no la ter t11an five ou-51ness days a fte1 the unlawfu l or unauihonzetJ access use or disclosure has been detected by tl1e cl1 n1c I eaIth fac il ity ome t1ealtl agency or hospice (bJ 12 i Sut iect to subd1v1s1 on (CJ a cl inic heal h fac1li y l1orne health agency or hospice shall also repo1 t any u1law ful or unau t 1onzed access to or use or disclosure ot a pat ient s rned1ca l 11 fonn at1011 lo the affec ted patient or the p31ent s represen ta tive at the las 1-nown add ress no later than five business days after the unlawfmiddotu1or unauthorized access use 01 d isclosure has been de tected by the c lin ic health facltty home healt1 agenly or hospice

l his Stmu tbull~ 1s not met ilS evidenced by

1280 lgt ibi(2) Healt11 Sa fe ty Code 1280

tb) 2 J Subject to suorJ 1v1s1on (c) a clinic t1eal th fac1l 1ty home l1ealth agency or hosp ice snail also report any un lawful or unauthorized access to or use or d isclosure o f a patients med ical 111 form at1on o the a ffec ted pa tient or the patients representative at the last known address no later than five business days after the unlawfu l or unauthorized access use or disc losure has been detected by the cl inic healt l1 faci lity horne health

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Cal1forn1a Deoartment of Public Hea th

sr-1ff r1-NI I J Ut rlC-t NClS l kOVIGLl~~UfH If RC I I_ ~J I 1 pmiddoti 1 tJ (f 1-rlt ri- 1middot1bull1H~ ltJt N IJ- L1 l t J rJLl~oH-

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~ ri -j liMi 1 A f~ Y sf I I N r U Imiddot m tlCil iC ll s llJ ik011rbulll11 S lI N 0 1 CCJR l~EC I ION lmiddot 1 111- tmiddot l-iO l ktH1-1C bulll IJff lCi[ IH~Y r us r GL RtCtLH lJ 8yen f ltJI I 1CbullCl-I O H i~ CI Vl AC Tllt)N Shlt) lJI U BE u r11r 1r

I 1ltr- 1)U 1A l 1P t -RI SC IDFNlt- YING l l ~ U H lmiddotf1 1 raquo~ 1 r01J ilt lt JS~ IU l-lHlmiddot Ntn 10 1111- PPR 11gt f f l middot 11

ULI IC llmiddot CY1

p u i 0 Continued Fro rn page 5

agency or hos p i ce~

fh1s Statute 1s nor n1et as evidenced by Based on 1nterv1ew and record review the ac1hly fa iled to 11 forin two affected patients of middot 11 au thonzed access to their med1c3 1111 format1on 110 later tl1an five b L s1ness days after 1t had IJeen detected w a1ents 1 and 2)

r 1nd111gs

Dunng an 1nte1 1ew 0116221l at 0 25 am Ad1rnn1stra ive (Ad m111) Staff A confi rmed lie follow1ng

Fram 1 11 to gt1 11 Custo1ner Service Representative C 111 appropnately accessed portions of Patients 1 and 2s electronic medical records multiple tunes w1t11out the proper aut11onzat1011 l he fac1il ly became awa re of the unau r1onzed access on 52511 al 823 am

1 ~ a t1ent i v1as notified o tile nau thonzed access on 6115 1 at pill ly tltlepl10ne and t11 e11 by letter on 61 6 11 Pa11en t 2 was not1f1ed of t11amp unauthonzeo access on 6 1611 by letter folio 11119 an unsuccessful telephone atte1 pt

Adm 1n Staff A ltJcknowledged middothat Patients 1 antJ 2 si1ould have been 1middot ot1f1ed by 6121 1 wh1c l1 would have bee11w1tli111 5 bus111ess days rom the 1dent1f1ca t1011 of the 1nauthorized access

The facilny was 14 ca lendar days late 111 report in g the unauthorized access to Patien t 1 and 15 calendar days late in report1119 the Lii autho rized

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5974 PENTZ ROAD FEATHER RIVER HOSPITAL PARADISE CA 95969

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rmiddot~r r middot i- [ACll Dff lCI~ NiY lIUSI Bt lRECtOl[J llf FlI L Pffrllt 1CltCH CORR EC IVI AC I li)M SI iJU LD St 11 -11-1 L IE middot-A i l~ F(U1 A l(J RY OR I ltC IDE t- 111-Yll INf r_)f~1 1 110 I roc~ CHOiS RfftrltENC lmiddotIJ IU fH f 1ilflt()fH lf f f r1 11middot

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P- 01 - Conunued From page 2 A 01

Based on 1nterv1ew and record review the ac1il ty failed to safegua rd confident1a health mformat1on or tvJO patients Pa tien ts 1 ancl 2J

011 616l 1 al 4 22 pni t11e Californ ia Depar 1 erll of l)ubl1c Heall CDPH ) received a faxed repoll writ ten by Adm1nistrat1vt fldmin) Stal A w h1c1middot1 indicated t11at the middotac1lrly l1ad 1dent1fied unaut11oriLed access of Pat1enmiddots 1 and 2s persona healt11 1nforrnat1on on 5125111 a 8 L3 am

Dur 1ng an 1ntuv1bull2w or G2211 at 10 2gt am Ad1111n (Adm1n) Staff and Adm1n B stated that Customer Serv ice Represer tauve (CSR ) C t1ad l)een term inate after 1t was determir ied tlla t she -gt

11 ad been inappropriately accessing and viewing = shyI-

portions of Patients 1 and 2s electron ic rned1cal D -middot- _I

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and t1ad accessed multi ple parts of th eir medical - - - 7 ~ t-~

CJ - shy--- Drecords Th is 1nformat1on 1r1cluded middot names gtI0 middotmiddot-middotshyadd resses social security numbers phone o ~ -0 -shynumbers insurance date of appointments 3D emiddot i-i-

nursing notes medications phys1c1ans progress () ~ --notes encoun ter 1s1ts notes and diagnosis lists N ()

CSR C employee file was re iewed A docu ment titled Fea ther Ri er Hospital Conf1dent1ality Ag reement dated and signed by CSR C on 1112003 read It is the policy of Feather R1ve1 Hospital to rna111ta1n confidential 1nformat1on i11 strrct confidence both while at work and off uuty It is aiso the respons1btl ity of any who have contact with confidential 1nforrnat1on to preserve s ich records against loss destruction tarnper111g and 111 appropr1ate access and us Any breach of confidential ity rep resents a fa ilure to meet tt1e legal professional and e h1 ca t standarmiddotds

L1oens111g ano Cert1f1ca11on D1111s1on

SfAIE FORM H 1 ~W t

I

-JQ11Q1Jl1a Depa rtment of Put)l1c Health

~gt 11~ I l l N I OF l) E F L ~ J C 1 i $

1 1middot1 lt 11r CORREC1 11J 1

FEATHER RIVER HOSPITAL

1X 11 f f()VlJt RISUPl I If- RICI 1 liJEt l I - 1( I lt)N U iltJ lI

CA230000005

I I() SUI ~ 11RY 3 [ f EMEN I or Olf lCIF NCll s l i~ r 1-i li tCACH DEF ICIENCY MUS I llE fRlCEOllJ lY l ULL

~ -~ -( 1 ( l l A I ORY OR I Sr I Lbull Fr-H ~ Y i N r llltt- U lM1 1 0~

A o 11 Co11 t11ued From page ~

expected and constitutes a vio lation of this policy A breacl1 need not take the form of a delibera te ci ternp t to viol ate conf1de 11 t1ali ty bu t includes any L nnecessary or unau l1onzed use or disclosure ot co 11 f1dent1al 1nform at1011 - due to ca relessness cu nosrty or co icern or for personal gain or malice 1nc lud111g but r c t res tricted to mformal d iscussion

A document titled Em ployee 0 1sc1pltnary Action l~eport middotdated 5125 11 read On more l1an or e occas ion you (CSR C) l1 ave accessed pro tecteo heal th 111forrnation of your family (Pat10nts 1 and 2) This is a direct rolat10 11 omiddot fac1l 1tys pol1cres You (CSR C Jhave had Il l rn erous train ing regard ing t1e po li cies relat ing to privacy and HIPAA (Heal h Insurance Portabil ity and Accou nta tJ1lity Act J

During a 11 1nterv1ew and document review on 622111 at 1205 pm wrth Ad rn1 11 A CSR Cs computer log reports were reviewed from 1 1 11 th ro ugh 5125111 According to Adm1n A the audit sl1owed t11at there was a pa ttern of excessive inappropri ate anu una thonzed access ing of Patien ts 1 and 2s medical records On 5125111 C SR C was terminated by tl1e facili ty for v1 o law1g the facrl1ty s policy and procedures by accessing her fa r dys protected health 1nformat1on

I he facil1ty failed to preve nt unlawfu l o r una thonzed access to and use or disclosure o f patients rneli 1cal information accord ing to Health and Safety Code Section 1280 15a )

A 018 1280 15t b)( 1) Health amp Safety Code middot12so

(b) (1) A clin ic hea lth faci lity home health agency or hospice to which subd ivision (a) applies shal l report any un lawful or unauthorized

- r l it 1 1bullu r1 gJs1 1iuc r1 )

r-- f3 U t LlJll ~G

8 WING _ _____

STREEr AOURf S S Cil r S Tff F ZIP Clt) [ [

5974 PENTZ ROAD PARADISE CA 95969

bullo bulll~l r IX

rAG

Pl lOIU lfi S lLNJ lt) t CO RtC I UN ~AClI CUHrH( loE AC I ILJN SHOUl [J GI

CPOSS RI r I iimiddot I c 1 D I 0 rHt Affmiddotf () f ilt li I t rgt1 F1C 1E NC f I

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A i U 11 sur vr f CU~1 P i rmiddot 11 [

c 06222011

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L 1 ei~ns 1ng a 11d C e r1bull1rca11on Drv1$10n

STATE FORM H 14W 11

l l middot IN lTD 03126Lll 12 FORM Pl FWVED

Ca lifornia Department of Publ ic Health

iibull I 1lt11 N bullJ UU middot IL I Cll S J OA r E SUINY ) middot PROlllJl HiSUPPc If RiC IA bullrJI i i - N ( )f bull bull) llfrL 11lt r C lt1M P F l i-l)11bull1 N 111 1c ~ ruiN N1Jr--rn1

c CA230000005 061222011

S IHt l AUDRtSS C IY Sfiltll Lii Clt)l lr

5974 PENTZ ROAD FEATHER RIVER HOSPITAL PARADISE CA 95969

X4 ll

l lltI 1-1~

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fl u 1 ~middot

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I~ ObbullJLA ro1ltYOH I SC IUL N rIF YING INFOHM n -NJ

C tJ1 1t1riued Fro rn page 4

3Ccess to or use or disclos ure of a pa t1 e1ts medica l inform ation to tt1e department no la ter t11an five ou-51ness days a fte1 the unlawfu l or unauihonzetJ access use or disclosure has been detected by tl1e cl1 n1c I eaIth fac il ity ome t1ealtl agency or hospice (bJ 12 i Sut iect to subd1v1s1 on (CJ a cl inic heal h fac1li y l1orne health agency or hospice shall also repo1 t any u1law ful or unau t 1onzed access to or use or disclosure ot a pat ient s rned1ca l 11 fonn at1011 lo the affec ted patient or the p31ent s represen ta tive at the las 1-nown add ress no later than five business days after the unlawfmiddotu1or unauthorized access use 01 d isclosure has been de tected by the c lin ic health facltty home healt1 agenly or hospice

l his Stmu tbull~ 1s not met ilS evidenced by

1280 lgt ibi(2) Healt11 Sa fe ty Code 1280

tb) 2 J Subject to suorJ 1v1s1on (c) a clinic t1eal th fac1l 1ty home l1ealth agency or hosp ice snail also report any un lawful or unauthorized access to or use or d isclosure o f a patients med ical 111 form at1on o the a ffec ted pa tient or the patients representative at the last known address no later than five business days after the unlawfu l or unauthorized access use or disc losure has been detected by the cl inic healt l1 faci lity horne health

10 RtI I

AG

1 middot 1~0 I DERS Pl AN lX co1mt c I IUN 1t1Cfl COHRECllV[ _ llt)N SHOULD oE

CHIJSS llt H-U[ NClO r) 11u- APPfltcW HIA I E QH ICifNC YI

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L1cen ~111 g a11d CE1t1fltca tto11 D1v1s1on

STATE FORM H1 4W11

1- 1~ 1 r I CD 032612012 F)fM APPROVlU

Cal1forn1a Deoartment of Public Hea th

sr-1ff r1-NI I J Ut rlC-t NClS l kOVIGLl~~UfH If RC I I_ ~J I 1 pmiddoti 1 tJ (f 1-rlt ri- 1middot1bull1H~ ltJt N IJ- L1 l t J rJLl~oH-

CA230000005

lt~middot I Di-E SUllV iC Mrll lt 0

c 06222011

5974 PENTZ ROAD FEATHER RIVER HOSPITAL PARADISE CA 95969

~ ri -j liMi 1 A f~ Y sf I I N r U Imiddot m tlCil iC ll s llJ ik011rbulll11 S lI N 0 1 CCJR l~EC I ION lmiddot 1 111- tmiddot l-iO l ktH1-1C bulll IJff lCi[ IH~Y r us r GL RtCtLH lJ 8yen f ltJI I 1CbullCl-I O H i~ CI Vl AC Tllt)N Shlt) lJI U BE u r11r 1r

I 1ltr- 1)U 1A l 1P t -RI SC IDFNlt- YING l l ~ U H lmiddotf1 1 raquo~ 1 r01J ilt lt JS~ IU l-lHlmiddot Ntn 10 1111- PPR 11gt f f l middot 11

ULI IC llmiddot CY1

p u i 0 Continued Fro rn page 5

agency or hos p i ce~

fh1s Statute 1s nor n1et as evidenced by Based on 1nterv1ew and record review the ac1hly fa iled to 11 forin two affected patients of middot 11 au thonzed access to their med1c3 1111 format1on 110 later tl1an five b L s1ness days after 1t had IJeen detected w a1ents 1 and 2)

r 1nd111gs

Dunng an 1nte1 1ew 0116221l at 0 25 am Ad1rnn1stra ive (Ad m111) Staff A confi rmed lie follow1ng

Fram 1 11 to gt1 11 Custo1ner Service Representative C 111 appropnately accessed portions of Patients 1 and 2s electronic medical records multiple tunes w1t11out the proper aut11onzat1011 l he fac1il ly became awa re of the unau r1onzed access on 52511 al 823 am

1 ~ a t1ent i v1as notified o tile nau thonzed access on 6115 1 at pill ly tltlepl10ne and t11 e11 by letter on 61 6 11 Pa11en t 2 was not1f1ed of t11amp unauthonzeo access on 6 1611 by letter folio 11119 an unsuccessful telephone atte1 pt

Adm 1n Staff A ltJcknowledged middothat Patients 1 antJ 2 si1ould have been 1middot ot1f1ed by 6121 1 wh1c l1 would have bee11w1tli111 5 bus111ess days rom the 1dent1f1ca t1011 of the 1nauthorized access

The facilny was 14 ca lendar days late 111 report in g the unauthorized access to Patien t 1 and 15 calendar days late in report1119 the Lii autho rized

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Ltcensu1 y ana Cer1 1fi1atio n DltSion

STATE FORM H 14 NI1

-JQ11Q1Jl1a Depa rtment of Put)l1c Health

~gt 11~ I l l N I OF l) E F L ~ J C 1 i $

1 1middot1 lt 11r CORREC1 11J 1

FEATHER RIVER HOSPITAL

1X 11 f f()VlJt RISUPl I If- RICI 1 liJEt l I - 1( I lt)N U iltJ lI

CA230000005

I I() SUI ~ 11RY 3 [ f EMEN I or Olf lCIF NCll s l i~ r 1-i li tCACH DEF ICIENCY MUS I llE fRlCEOllJ lY l ULL

~ -~ -( 1 ( l l A I ORY OR I Sr I Lbull Fr-H ~ Y i N r llltt- U lM1 1 0~

A o 11 Co11 t11ued From page ~

expected and constitutes a vio lation of this policy A breacl1 need not take the form of a delibera te ci ternp t to viol ate conf1de 11 t1ali ty bu t includes any L nnecessary or unau l1onzed use or disclosure ot co 11 f1dent1al 1nform at1011 - due to ca relessness cu nosrty or co icern or for personal gain or malice 1nc lud111g but r c t res tricted to mformal d iscussion

A document titled Em ployee 0 1sc1pltnary Action l~eport middotdated 5125 11 read On more l1an or e occas ion you (CSR C) l1 ave accessed pro tecteo heal th 111forrnation of your family (Pat10nts 1 and 2) This is a direct rolat10 11 omiddot fac1l 1tys pol1cres You (CSR C Jhave had Il l rn erous train ing regard ing t1e po li cies relat ing to privacy and HIPAA (Heal h Insurance Portabil ity and Accou nta tJ1lity Act J

During a 11 1nterv1ew and document review on 622111 at 1205 pm wrth Ad rn1 11 A CSR Cs computer log reports were reviewed from 1 1 11 th ro ugh 5125111 According to Adm1n A the audit sl1owed t11at there was a pa ttern of excessive inappropri ate anu una thonzed access ing of Patien ts 1 and 2s medical records On 5125111 C SR C was terminated by tl1e facili ty for v1 o law1g the facrl1ty s policy and procedures by accessing her fa r dys protected health 1nformat1on

I he facil1ty failed to preve nt unlawfu l o r una thonzed access to and use or disclosure o f patients rneli 1cal information accord ing to Health and Safety Code Section 1280 15a )

A 018 1280 15t b)( 1) Health amp Safety Code middot12so

(b) (1) A clin ic hea lth faci lity home health agency or hospice to which subd ivision (a) applies shal l report any un lawful or unauthorized

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C tJ1 1t1riued Fro rn page 4

3Ccess to or use or disclos ure of a pa t1 e1ts medica l inform ation to tt1e department no la ter t11an five ou-51ness days a fte1 the unlawfu l or unauihonzetJ access use or disclosure has been detected by tl1e cl1 n1c I eaIth fac il ity ome t1ealtl agency or hospice (bJ 12 i Sut iect to subd1v1s1 on (CJ a cl inic heal h fac1li y l1orne health agency or hospice shall also repo1 t any u1law ful or unau t 1onzed access to or use or disclosure ot a pat ient s rned1ca l 11 fonn at1011 lo the affec ted patient or the p31ent s represen ta tive at the las 1-nown add ress no later than five business days after the unlawfmiddotu1or unauthorized access use 01 d isclosure has been de tected by the c lin ic health facltty home healt1 agenly or hospice

l his Stmu tbull~ 1s not met ilS evidenced by

1280 lgt ibi(2) Healt11 Sa fe ty Code 1280

tb) 2 J Subject to suorJ 1v1s1on (c) a clinic t1eal th fac1l 1ty home l1ealth agency or hosp ice snail also report any un lawful or unauthorized access to or use or d isclosure o f a patients med ical 111 form at1on o the a ffec ted pa tient or the patients representative at the last known address no later than five business days after the unlawfu l or unauthorized access use or disc losure has been detected by the cl inic healt l1 faci lity horne health

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I 1ltr- 1)U 1A l 1P t -RI SC IDFNlt- YING l l ~ U H lmiddotf1 1 raquo~ 1 r01J ilt lt JS~ IU l-lHlmiddot Ntn 10 1111- PPR 11gt f f l middot 11

ULI IC llmiddot CY1

p u i 0 Continued Fro rn page 5

agency or hos p i ce~

fh1s Statute 1s nor n1et as evidenced by Based on 1nterv1ew and record review the ac1hly fa iled to 11 forin two affected patients of middot 11 au thonzed access to their med1c3 1111 format1on 110 later tl1an five b L s1ness days after 1t had IJeen detected w a1ents 1 and 2)

r 1nd111gs

Dunng an 1nte1 1ew 0116221l at 0 25 am Ad1rnn1stra ive (Ad m111) Staff A confi rmed lie follow1ng

Fram 1 11 to gt1 11 Custo1ner Service Representative C 111 appropnately accessed portions of Patients 1 and 2s electronic medical records multiple tunes w1t11out the proper aut11onzat1011 l he fac1il ly became awa re of the unau r1onzed access on 52511 al 823 am

1 ~ a t1ent i v1as notified o tile nau thonzed access on 6115 1 at pill ly tltlepl10ne and t11 e11 by letter on 61 6 11 Pa11en t 2 was not1f1ed of t11amp unauthonzeo access on 6 1611 by letter folio 11119 an unsuccessful telephone atte1 pt

Adm 1n Staff A ltJcknowledged middothat Patients 1 antJ 2 si1ould have been 1middot ot1f1ed by 6121 1 wh1c l1 would have bee11w1tli111 5 bus111ess days rom the 1dent1f1ca t1011 of the 1nauthorized access

The facilny was 14 ca lendar days late 111 report in g the unauthorized access to Patien t 1 and 15 calendar days late in report1119 the Lii autho rized

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3Ccess to or use or disclos ure of a pa t1 e1ts medica l inform ation to tt1e department no la ter t11an five ou-51ness days a fte1 the unlawfu l or unauihonzetJ access use or disclosure has been detected by tl1e cl1 n1c I eaIth fac il ity ome t1ealtl agency or hospice (bJ 12 i Sut iect to subd1v1s1 on (CJ a cl inic heal h fac1li y l1orne health agency or hospice shall also repo1 t any u1law ful or unau t 1onzed access to or use or disclosure ot a pat ient s rned1ca l 11 fonn at1011 lo the affec ted patient or the p31ent s represen ta tive at the las 1-nown add ress no later than five business days after the unlawfmiddotu1or unauthorized access use 01 d isclosure has been de tected by the c lin ic health facltty home healt1 agenly or hospice

l his Stmu tbull~ 1s not met ilS evidenced by

1280 lgt ibi(2) Healt11 Sa fe ty Code 1280

tb) 2 J Subject to suorJ 1v1s1on (c) a clinic t1eal th fac1l 1ty home l1ealth agency or hosp ice snail also report any un lawful or unauthorized access to or use or d isclosure o f a patients med ical 111 form at1on o the a ffec ted pa tient or the patients representative at the last known address no later than five business days after the unlawfu l or unauthorized access use or disc losure has been detected by the cl inic healt l1 faci lity horne health

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I 1ltr- 1)U 1A l 1P t -RI SC IDFNlt- YING l l ~ U H lmiddotf1 1 raquo~ 1 r01J ilt lt JS~ IU l-lHlmiddot Ntn 10 1111- PPR 11gt f f l middot 11

ULI IC llmiddot CY1

p u i 0 Continued Fro rn page 5

agency or hos p i ce~

fh1s Statute 1s nor n1et as evidenced by Based on 1nterv1ew and record review the ac1hly fa iled to 11 forin two affected patients of middot 11 au thonzed access to their med1c3 1111 format1on 110 later tl1an five b L s1ness days after 1t had IJeen detected w a1ents 1 and 2)

r 1nd111gs

Dunng an 1nte1 1ew 0116221l at 0 25 am Ad1rnn1stra ive (Ad m111) Staff A confi rmed lie follow1ng

Fram 1 11 to gt1 11 Custo1ner Service Representative C 111 appropnately accessed portions of Patients 1 and 2s electronic medical records multiple tunes w1t11out the proper aut11onzat1011 l he fac1il ly became awa re of the unau r1onzed access on 52511 al 823 am

1 ~ a t1ent i v1as notified o tile nau thonzed access on 6115 1 at pill ly tltlepl10ne and t11 e11 by letter on 61 6 11 Pa11en t 2 was not1f1ed of t11amp unauthonzeo access on 6 1611 by letter folio 11119 an unsuccessful telephone atte1 pt

Adm 1n Staff A ltJcknowledged middothat Patients 1 antJ 2 si1ould have been 1middot ot1f1ed by 6121 1 wh1c l1 would have bee11w1tli111 5 bus111ess days rom the 1dent1f1ca t1011 of the 1nauthorized access

The facilny was 14 ca lendar days late 111 report in g the unauthorized access to Patien t 1 and 15 calendar days late in report1119 the Lii autho rized

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ULI IC llmiddot CY1

p u i 0 Continued Fro rn page 5

agency or hos p i ce~

fh1s Statute 1s nor n1et as evidenced by Based on 1nterv1ew and record review the ac1hly fa iled to 11 forin two affected patients of middot 11 au thonzed access to their med1c3 1111 format1on 110 later tl1an five b L s1ness days after 1t had IJeen detected w a1ents 1 and 2)

r 1nd111gs

Dunng an 1nte1 1ew 0116221l at 0 25 am Ad1rnn1stra ive (Ad m111) Staff A confi rmed lie follow1ng

Fram 1 11 to gt1 11 Custo1ner Service Representative C 111 appropnately accessed portions of Patients 1 and 2s electronic medical records multiple tunes w1t11out the proper aut11onzat1011 l he fac1il ly became awa re of the unau r1onzed access on 52511 al 823 am

1 ~ a t1ent i v1as notified o tile nau thonzed access on 6115 1 at pill ly tltlepl10ne and t11 e11 by letter on 61 6 11 Pa11en t 2 was not1f1ed of t11amp unauthonzeo access on 6 1611 by letter folio 11119 an unsuccessful telephone atte1 pt

Adm 1n Staff A ltJcknowledged middothat Patients 1 antJ 2 si1ould have been 1middot ot1f1ed by 6121 1 wh1c l1 would have bee11w1tli111 5 bus111ess days rom the 1dent1f1ca t1011 of the 1nauthorized access

The facilny was 14 ca lendar days late 111 report in g the unauthorized access to Patien t 1 and 15 calendar days late in report1119 the Lii autho rized

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U) I a cl1n1c l1ealll1 f3c1 1ty t101ne 11eal h agency or hc spice to m1c l1subd1v1s1on (a) applies vola es subo1vis1011 1b the d1partment nay assess the l1cens bulle a penalty 1n the amount of one hu11d1ed dollars ($1001 for eaci1 cJay that the Lnla vfu l or nauthonzeli access use or disclosure 1s not 1eported fo llowing the 1111t1 a l five-dc1y period spec1 f1ed rn subd1v1s1011 (b) Howe ve1- the~ total COlllb1ncd penalty assesserJ oy the department under subdiv1s1on (aJ cind t111s sut1d1v1s101 si1a lt not exceed two hu11drebullj fifty t11ousand dbullJllars ($250 000) per reported even t

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1 Durmy a11 111 ter 1euroW on 622 11 at 10 25 anmiddot Adminstratr e (Ad 111111 1Staff A confirmed t11e fol lowing

From 111 to 511 Customer Se1111ce Representati ve C mappropriately accessed portions of Patients 1 and 2s electronic medica l records multiple times without t11e prope au thorization The faci lity became aware of the

l1cens111g and Cen1fcalon 0 1 1sion

STATE FORM H14Wll

Cal1forn1a Depannient of Public Hea lth

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f l I~ ctjULA 11 IJ~ middot u~ L~ I ~ lL ~ ~J 111 r l imiddot~ (i INf i )l~~lA I 18 r-bull l~ J- oss IH ITRC NCEJ I 0 r I IL Afl ROPRIATl Llmiddot Ir rJiT lbull lr NCY

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u11 aull 1or1Led access 011 5125111 at 8 23 am

Pa 1ent 1 1ivc1s noti fied of he una t11ori zed access 01 61511 at 1 pn by telephole and her by iette1on 616 11 Pat ient 2 was not1f1ec1of t11 e unauthorized acc-2SS on 61 16 11 by le tter following an u1 successf 1telephone atremr

J rrnn Sta f A ac~11owledged that Patients 1 lt111ltj 2 shou ld have been r otrf re by 62111 wh ich wou ld I abull1e bee11 1111 ti1111 5 bus111 ess days from tile 11je11 t1f1cat1on of the 1J11autl101middotized access The fa c1l1ty wds middot14 calendar days la te 111 reporting the unautl ion7td riccess to Pauen t 1 and 15 calendar ays late in reporting the u 1authonzed access o r-v

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hJJgt- - --1l 2 Du ri ng an 1 itervrew on 622 11 at lO 25 am -- u-- -

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From 11 1 through 511 Cu stomer Servrce c middot =x r-n Representabullive C inappropria tely accessed w middot-5 portions of fgtat1ents 1 and 2s electro111c medical rv re ormiddotds 1nult1ple t1 rnes w1tl1out the prnper lD

aut11orizat1on fll is informat101 111cluded names addresses socia l stcun ty numbers phone r um bers insurance date of app0111 tments

nlt rs tng notes med1cat1ons pl1ys1c1ans p rogre~ notes encounter v1s1s notes and diagnosis lists

rne tccrl1ly became amiddotva1 e of the unautl1onzed access on 525 11 at 8middot23 am CDPH was not1f1ed or the u11authon1td acce ss by fax on 61611 a 4 22 am

Adm111 Staff A acknowledged that CDPH S llOL Id have been not1f1ed by 62 11 which would have been with in 5 business days from the ident1flcation of tile unautl onzed access

L1cc ns1 n9 antl Ceri 1fica11on D1v1s1on S f ATE FORM H14VV I

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u11 aull 1or1Led access 011 5125111 at 8 23 am

Pa 1ent 1 1ivc1s noti fied of he una t11ori zed access 01 61511 at 1 pn by telephole and her by iette1on 616 11 Pat ient 2 was not1f1ec1of t11 e unauthorized acc-2SS on 61 16 11 by le tter following an u1 successf 1telephone atremr

J rrnn Sta f A ac~11owledged that Patients 1 lt111ltj 2 shou ld have been r otrf re by 62111 wh ich wou ld I abull1e bee11 1111 ti1111 5 bus111 ess days from tile 11je11 t1f1cat1on of the 1J11autl101middotized access The fa c1l1ty wds middot14 calendar days la te 111 reporting the unautl ion7td riccess to Pauen t 1 and 15 calendar ays late in reporting the u 1authonzed access o r-v

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hJJgt- - --1l 2 Du ri ng an 1 itervrew on 622 11 at lO 25 am -- u-- -

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aut11orizat1on fll is informat101 111cluded names addresses socia l stcun ty numbers phone r um bers insurance date of app0111 tments

nlt rs tng notes med1cat1ons pl1ys1c1ans p rogre~ notes encounter v1s1s notes and diagnosis lists

rne tccrl1ly became amiddotva1 e of the unautl1onzed access on 525 11 at 8middot23 am CDPH was not1f1ed or the u11authon1td acce ss by fax on 61611 a 4 22 am

Adm111 Staff A acknowledged that CDPH S llOL Id have been not1f1ed by 62 11 which would have been with in 5 business days from the ident1flcation of tile unautl onzed access

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5974 PENTZ ROADFE A THE R RIVER HOSPITAL PARADISE CA 95969

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~middotucirIAR $1A l tk11 o r IJf r lC l c ~JC ll middot i U Pk) VUCF(S Pt A1 1J F iOFmiddotlHEC 1iO N ~ 5 1

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5974 PENTZ ROADFE A THE R RIVER HOSPITAL PARADISE CA 95969

bull ~3 Omiddot 1L SUHit Y Clt lMlU I ~ IJ

c 06222011

~middotucirIAR $1A l tk11 o r IJf r lC l c ~JC ll middot i U Pk) VUCF(S Pt A1 1J F iOFmiddotlHEC 1iO N ~ 5 1

l-1lt11 11 1r ACi- D l fllt~ IErcY f11U31 Br_Flltl lr rxo B ( r-u tL 11H CO l~REC nvrmiddot rc f lON SHOULD Bl 1lt MPtFH Xmiddotl bull llJ

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