CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH STATI:MENT OF OEFICIENCIES (X1J PROVl>ER/SUPPLIER/CI.IA (X2) MIJI. TIP\.E CONSTRUCTION 1)(3) 0ATE SVRVEY AND Pl.AH OF COME'CTlON IOEHTIFICATION NUMSEft COMPLETED A. IIUlOING 065498 11.WIHG 02/ 10 /2011 NAME Of PROVIDER OR SUPPLIER 8TRE~ ADDRESS, CITY , STATE,2JP CODE THE SEQUOIAS 501 PORTOLA ROAD, PORTOLA VALL£Y, CA 94028 SAN MATEO COUNTY ()t,ljlll 9V1,1W.RV 8TATEMEHT OF DEFICIENCIES ID PREFIX \EACH CliFICIENCY MUST Bl! PR!!CEEDED fN f utl PREFIX TAG REQI.A.ATORY OR LSC IOENTJFYINQ INfO!WATlOH) TAG The foUowing reflecte the nndlngs of the Department of Public Health durlllQ a c;omplainl/breach evem visit: Complalnt Intake Number: CA00257652 • Substantiated Representing the Depanment of Pubffc Health: Surveyor ID# 18973, HFEN The Inspection was llmlted to the specmc facUtty event investigated and does not represent the findings of a fud Inspection of the faclll~. Heaflh and Safety Code Section 1280.15(a) A clinic, health facility, home health agency, or hospice \lcensed purauant to Section 1204, 1250, 1725, or H45 shalt prevent unlawful or unauthorized access to, and use or disclosure of, patients' medical Information, es denned in subdlVislon· (9) of Section 66.05 of the Civil Code end consistent wilh Section 130203. The department, ofter Investigation, may assess en admlnlstraUve penalty for a vlolaUon of this section of up to twenty-five thousand d011a·rs ($25,000) per patient whose medical Information was unlawfully or without authorization accessed, used, or disclosed, and up to seventeen thousand rive hundred dollars ($17,500) per subsequent occurrence of unlawful or unauthorized access, \JSe,. or disclosure of that patients' med!cal Information. Informed Medlcel Breach Health & Safety Code 1280.15(b)(2) PROVIIE!nl Pl.AH Of CORRECTIOH ()(5) (!!ACH OORRECll'l'I! ACTION SttOIJUl Ill! CROSS, COIIPtETli. REfl:Re!CEO TO 1HI! APPROPRIATE DEFICIENCY) OAlli 1bis unauthorized disclosure event was corrected by withdrawing the offending cotnlllent from the posting location on the .internet website on februaty 3, 2011, and notifyini the affected party within 4 days of our facility's awateness of the breach, as noted in the statement of deficiency. The staff member whose posting constituted the violation is no longer here. The NCPHS Personnel Policy bas been revised to detail the strict prohibition against using social media in any manner that compromises Protected Health Information, as well as other materials, data and infonnation o a proprietary nature belpnging to NCPHS. Director of Staff Development has conducted an in-service on June 21, 2011~ to review for c,,{ ~, ( ,, f 6/612011 1:36:49PM. Event 1D:35CN11 TOR'S OR PR~ERISUPPLIER REPRESENTATIVE'S SIGNA'rURE ,vt .... =:.;~ MY aencien~y elalement ending with en Hlerbk (') ctenotn • der,:;iency whl ,~ the lntijtu1Jon may be elCCUted rroin conectrng prol(idlng it 1, del•r mlntd 1~e1 oll\clr aaregu1rd1 p,ovlde ,ultlcltnt prOlaclion 10 tM p111tnls. Except tor nu11lng nomet, the r.ndlng1 abo~ aro dl1e10..ble 90 day, foflowlng the d1t1 of aurvoy whe1her01 not I plan of com<:Von J• p10\4ded. Fo, nu,.lng hornet, the above rindlngt end pll"' ot ootrocilon ere <fisdo"llle 14 day, f ollowing Ille date lheae documents are ,ude 1v1U1ble to the 11cYity . II der.cJencits are cited, an approved plan ot correclioo It requlsilll lo continued p1ogr1111 partlclpaUon. St<ile-2S67
Transcript
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH
STATIMENT OF OEFICIENCIES (X1J PROVlgtERSUPPLIERCIIA (X2) MIJITIPE CONSTRUCTION 1)(3) 0ATE SVRVEY AND PlAH OF COMECTlON IOEHTIFICATION NUMSEft COMPLETED
A IIUlOING
065498 11WIHG 02102011
NAME OfPROVIDER OR SUPPLIER 8TRE~ ADDRESS CITY STATE2JP CODE
THE SEQUOIAS 501 PORTOLA ROAD PORTOLA VALLpoundY CA 94028 SAN MATEO COUNTY
()tljlll 9V11WRV 8TATEMEHT OF DEFICIENCIES ID PREFIX EACH CliFICIENCY MUST Bl PRCEEDED fN f utl PREFIX
TAG REQIAATORY OR LSC IOENTJFYINQ INfOWATlOH) TAG
The foUowing reflecte the nndlngs of the Department of Public Health durlllQ a complainlbreach evem visit
Complalnt Intake Number CA00257652 bull Substantiated
Representing the Depanment of Pubffc Health Surveyor ID 18973 HFEN
The Inspection was llmlted to the specmc facUtty event investigated and does not represent the findings of a fud Inspection of the faclll~
Heaflh and Safety Code Section 128015(a) A clinic health facility home health agency or hospice lcensed purauant to Section 1204 1250 1725 or H45 shalt prevent unlawful or unauthorized access to and use or disclosure of patients medical Information es denned in subdlVislonmiddot (9) of Section 6605 of the Civil Code end consistent wilh Section 130203 The department ofter Investigation may assess en admlnlstraUve penalty for a vlolaUon of this section of up to twenty-five thousand d011amiddotrs ($25000) per patient whose medical Information was unlawfully or without authorization accessed used or disclosed and up to seventeen thousand rive hundred dollars ($17500) per subsequent occurrence of unlawful or unauthorized access JSe or disclosure of that patients medcal Information
Informed Medlcel Breach Health amp Safety Code 128015(b)(2)
1bis unauthorized disclosure event was corrected by withdrawing the offending cotnlllent from the posting location on the internet website on februaty 3 2011 and notifyinithe affected party within 4 days ofour facilitys awateness of the breach as noted in the statement of deficiency
The staff member whose posting constituted the violation is no longer here
The NCPHS Personnel Policy basbeen revised to detail the strict prohibition against using social media in any manner that compromises Protected Health Information as well as other materials data and infonnation oa proprietary nature belpnging to NCPHS
Director of Staff Development has conducted an in-service on June 21 2011~ to review for
c ~ (
f
6612011 13649PMEvent 1D35CN11
TORS OR PR~ERISUPPLIER REPRESENTATIVES SIGNArURE
vt=~ MY aencien~y elalement ending with en Hlerbk () ctenotn bull deriency whl~ the lntijtu1Jon may be elCCUted rroin conectrng prol(idlng it 1 delbullrmlntd
1~e1 ollclr aaregu1rd1 povlde ultlcltnt prOlaclion 10 tM p111tnls Except tor nu11lng nomet the rndlng1 abo~ aro dl1e10ble 90day foflowlng the d1t1 of aurvoy whe1her01 not I plan of comltVon Jbull p104ded Fo nulng hornet the above rindlngt end pll ot ootrocilon ere ltfisdollle 14 day following Ille date lheae documents are ude 1v1U1ble to the 11cYity II dercJencits are cited an approved plan otcorreclioo It requlsilll lo continued p1ogr1111
partlclpaUon
Stltile-2S67
IX~l to 8UMwRYSTATElENT OF DEFlCIENCIES 10 RlfC( (EACH OEFICIENCY MUST BE PRECEEOED BV FUU PRiFllC TAO REGULA10RI Oil LSC IPOOtrnNO INFORMATION) TAG
ConUnuad From pagbull 1
Health and Safety Code Socllon 128015 (b)(2 A clinic heaHh facility agency or hospice ahall also report any unlawful or unauthorized acceu to or use or dlsclosulB of a patients medical Information to the affected patient or the patlenrs repr91entative a1 he last known addreH no later than five business days after the unlawful or unauthorized access use or disclosure hes been detected by 1ha clinic health faclllty agency or h~pkEt
The CDPH verified that lhe faclllty informed tha affected pallent(e) or lhe pallanfs representalve(a) of Iha unlawful or unauthorized access use or dlecloaure of the paHents medical information
128015(8) Health amp Safety Code 1280 (a) A clinic health facility home heaHh agency or hospice licensed pul8uanl to Section 1204 1250 1725 or 1745 shall prevent unlawful or unaulhorized aceess lo and uae or dlscioaure of pa11ents medical lnfomatlon as defined In aubdlVaiOfI g) of SecUon 5605 of lhe Clvll Code and conslatenr with Section 130203 The deparlment after inY8sligatlon may assess an edm~ialraUve penalty for a vlolallon of this section of up to twenty-five thousand doOars ($25000) per patient whose medical lnfonnallon was unlawfully or without aulhorizalion accessed used or discloaed and up 10 aeventeen thousand five hundred dollars ($17500) per subsequent occurrence of unlawful or unauthorized access use or disclosure of that patients medical informalion For purposes of the investigation lhe department shall consider the
Health Center staff the nature of Protected Health Information (PHI) the requirement of the law to maintain strict confidentiality o PHI the procedures to follow in case a breach is discovered and the consequences ofany such breach for the facility and the stafmember(s) responsible
The Corporate Compliance Handbook was also reviewed in the In-service as was the Corporate Compliance Acknowledgment document signed in each employee file
The Administrator and the Director ofNursing Services maintain surveillance ofstaff communications - verbal and written - to assure that discussions ofPHI are not conducted publicly and thus overheard that documents are no1 exposed inappropriately during th course ofwork and are disposed
r (V I If
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH
(X1) PROVIOERISUPPLIEAALIII (lQ) MlllPLECONSTRUCTIONSTAlEMEtfT OF orflCIENCIES l(S)OAlE6URVEY IOEHTIFJCATION tIM8EIAMO PlNI OI CORRECTION COtlPlelEO
A IIVILOIHG
IIWING0~14$$ 0211012911
STREET AODRHS CITY STATE ZlP COOEIW11 Of PROVIDER OR 8UPPUER
S01 P0RTOLA ROAD PORTOLA VALLEY CA 94028 SAN MATfO COUNTYTHE SEQUOIAS
61812011 13649PM Event 1D36CN11
LABORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESENTATIVES SIGNATURE TtnE (KIi) OATE
MY deffdency 1111-Mtnl endillgwllh an aaltrtk ) dtnolea bull d1llcl1ncy which Iha i1111iulion-rn1y ~ elCUed ft0111 correcUng f)IOvldlnQ ll la deltbullrmlned lhel oher aara11111rd1 pro-ld euNlclenl protecton to lhe paUentt Ewopl fof nu11lng hom11 lhe findingbull abow re dlactoNble 90 dbullYI followlng Ille d11 of aurwy whother or not pla11 ol correction 11 pr~laquostd For nurilng homta tie eboVe lindlnga and planbull olcolaquooclion 1re dlsclonblbull 14d1y1 followlrg the dale lheH docum1n11 ere tnlda 1vall1ble lo tie rcJtty ti deficiencies aro cited an 1pprovod plan cl eorrection ls rcivltlte lo~tlnued PIOQlbullm
participation
- ---middot-- ---middot- - -shy
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENCY OfPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (XI) PROVDEMUPPLIERCllA (X2) MUITIPlE CONSTRUCTION ()(3) ()Alf SURVEY AND PlAH Of CORRECTIOlf DEHTIFICATION NUMBER
06488 A BUIDING
B WIG
COMPlETD
02102011
NAME Of PROYlOM OR SUPPLIER
THE SEQUOIAS
STREET A1l0f1E6S CllY STATE llP COOE
501 PORTOIA ROAD PORTOIA VALLlY CA 9-4028 SAN MATEO COUNTY
()(4)10 $1MMNIYSTATlMOO a OEFICIEICIEII I)
PREFIX (EACH DEFICIENCY MUST BE PRECeeDEO r(FUll PREFIX
TAO REGULATORY OI L6C lgtlHllfYING 1NfOIIWTlON) TAO
Continued From page 2 cllnlcs health fadlltys agencys or hoaplooII history of compliance with this section and other related state end federal statutes and tegulatlons themiddot exten to which the racgtty detected vloletiona and took preventative action to mnedlately corect and prevent past violations rran Rturrlng and factors outside tis control that reatrlcted the facBftys abllty to comply with lhla section The department shell have full discretion to consider all factors when detennlnlng the amount of an adrnnlstraliw penalty pun1uant to this llection
These Regulations were not met as evidenced by
Based on Interview and recortl review the facility felled to ensure the right of Resident A a well-known publlc pen1onallty to confidential treatment or health recortls when a lacilfty staff posted a comment on Realdent As Facebook page thanking her for being a patient at Iha facility This was a violation of Heatth amp Safety Code 128015(a prohfblllng unlawful disclosure of a patients medical Information Facebook is an lntampmet social networking site where people ahare Information wflh friends Some public pampn1onaliles have publle pages that can be acceased by anyone using Facebook
Findings
Review of a letter-from the facfllty dated 21311 to the Department indicated This letter Is lo inform you of a security breach with regard to certain tnformalion pertaining o a former resident of the skilled nursing facllity We were informed on
PROVIDERS PLAN OF CORRECTION (Xamp) (EACH COMECTIVE ACTION SH0Ul0 BE CROSS COMPLpoundTE
REFEREHCeD TO THE NPROPR~TE DEFICIENCY) DATE
of properly in the secure bonded shtedding facilities on premises
CDPH JUN 171011
Lampr -middotmiddot I bullbullI0 ll middot
c( i11
61612011 13641lfM
LA80RAT0RY DIRECTORmiddotS OR PROVIDERSUPPLIER REPRESpound1fTATIVES SIGNATURE TITlE (XB)DATE
Any dtllclenay 111tet11bullnl ending will an utetlsk (tdbullllotebull 11 delldency IWhlth lllbull lneijlUIJon mey be lllleused frotll oorreellllg povldlng II i$ dttannlo4lt1 ~ 1h11 other ureguenM p(Ollde autflclenl polclkgtn to the pdtnll Except or llllftlng hon1n 111bull lindlng 1bov1 r dlldoaablo to dey1 lollowlng lhbull dale ttJ or tUMy whlller or not a plen of correction r pmvlded For hurafllg llomee 1111 abo11e 11ndYIDI end pllllof correelion er dlldoaeble 14 day followlllg 12-_V ~ the dale lhue (focumenls ere t11altle ayallable lo lie 1eility Wdeflcleneltbull clktd enapprl)Yed plen ofcoroction1J requlslle lo conUnued progretll
p1rtldpaU011
Stalamp-2567 3 Of 0
Event I036CN11
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENpV OEPARTMENT OF PUBLIC HEALTH
XI) PROVIDERSUPPLIERCUA8TATEMEITT Of DEFICIENCIES (X21 IAULTIPLE CONSTRUCTION ()(3) DATE SURVEY IOENTlflCATION UMBE1ANO PlAA OF CORRECTION COMPUTED
A BUILDJHG
B VMG05586 02110(2011
STREET ADDREVS CITY STATE 21P COOE
THe SEQUOIAS 1501 PORTOLA ROAO PORTOLA VALLEY CA 94026 SAN MATEO COUNTY NAME Of PROIIIOER OR SUPPIIER
IX4) 10 $VMIWIY STA TMEHT Of DECIEHCIEO 11)
PREFl)C (EACH DElICllNCY war BE PRECEEOEO BY FVU PREFIX TAO Rf(Jl1ATORY OR ISC lllEHTFYlNG INfORIMTION) TAO
PROIIDERS PM OF CORRECTION (X6)(EACH COR~ECTM ACTION SHOULD BE CROSS COwgt~ETE
REFEAENCED TO THE APPROPRIATli DEFICIENCY) DATE
Continued From page 3
January 31 2011 lhat a (facility) employee hadposted the following on the public portion of tho former SNF (skilled nursing foelily) residentsFacebook page ____ thank you for alfowing us to care for you My staff will not forgetyour vlsll ln aecordance with Fuebook protocol a link lo lhla comment appeared lmmedlaety on the employees prlvale Facebook pege A viewer ofthat page could cUck on the common middot end be redlrecied to the former 19sidenrs Facebook page thereby leernfng the fOlmer restdenra Identity Althat point the viewer could infer thol the formor resident had been at the (fecllltys) skilled nursing fadnty baaed on the employees original corrvnent about care being provkled by the vl$II and on informa~on furnished by the employee on her Facebook page about her positron at the skilled nursing facmty Olvan the Fecebook architecture there was a polentlel disclosure lhen to persons receiving access to Iha employees private Facebook page We learned that middot~ had posted the Facebook entry on ~2010 We had the entry 1emoved on 2011 0n the basis of what was discovered we are providing written notification to the former resident In accordanca with legal requirementsshy
In a lelephone interview on 21011 at 1020am Iha Execulivo Director slaled She (Resident A) was dmitted only using her lnllials lo Identify her We
maintained her privacy the whole llmc she was here Wo didnt even uee her real namebull
RBlleW of a print-out of the posting on Resident As Facebook page revealed (Resident A) thank you
C D PH
JUN zJ 20tt
Lampr _-L middot~I Jt tv middot -bull
a
6182011 t3849PMEvent 1D36CN11
LABORATORY D1RfCT0RS OR PROllOERSUPPLIER REPRESEHTATIVES SIGNATURE TITLE (XB)OATE
Any derkh11Cy atalemant andlng lriDI an u 1tri1k ( )61no1 bull dellclency wlllcl Ille Tn1d1111on may be oxw11d rom corr1clin9 potld1ng II Ibull ltMt1rmlned 1h11 olhor 11t1guards provide tulllclonl proi~n IO Illbull p1cJn1a EXlpl to nur1lng homu he nndi)g1 above bullbullbull dlldo11bl 80 chtys ldlowlng 11o dale of wvoy 11lthethe or notbull plen or COlelttion la prowlAd Fo1 nu111110 homt1 lho above Rndlngt and p1111 01 coneltUon bullrbull dl t1011lllo I~ dayo IOllowlng the dale lhtso doc1111141111 ore mbulldbull avoiloblt ICgt lhbull taciity Ifdofoclanclo cited bullnaj)proved plan ol corocUon la requbtte 10 conlinued program partlcifMUon
501 PORTOLA ROAD PORTOLA VALLEY CA 94028 SAN MATEO COUNTY
(MJO SUMMMY 31bullm1tttr Qt- PffCIEtlCiES Q
PREFIX (EACH DEflCIEgtICY WSY BE PRECEEOED BY FOLL PREFI)(
rAG REOUIATORV CA L8C IDENTIFtNG INFORWllONJ rAG
Continued From page 4
for allowing us to care for you My sleH wll~not forget your viampIIbull It was dated 10 at 822 pm and showed the picture and full name of the lacllily employee (the Director or NUrslng) The same posting was also reflected ori the Director of Norilngo Facebook profile page under Recent Activitybull
Review of lhe facilitys 2008 Corporate CompllanC9 middot handbook for ManagerSupervisor p12 Health
Insurance Portability and Accounablllty Act (HIPM) indicated HfPM cfarlRampamp what protected heofth information can and cnnot be shared Our job Is to protect the privacy and confldenUallty of Iha residents we oerve Residents hava the right to their Protected Health lnlormatfon (PHI) PHI is anything that connects the resident to hisher Informationbull If you reveal PHI to someone who does not need to know ft you have violated a resklenta confldenllaity and have broken the law Hf PPA violations could result in Correctlve Aclon up to and Including termination11bull slrlclly prohibited to share PHI over the Internet end e-manbull
Review of the Director of Nursinge employee file ehowed her signature on a Corporate Compftance Aoknowludgment of ReGeipl and Review ol Booklet form under the statement I have reed and reviewed the (laclllty) Corporate Compliance Booklet with my Department Head or middot Supervisor and I understand my role and responsibility in adhering to Iha NCPHS Standards of Conduct The ManagerJSupervlsorbull booklet that contained the HIPM p91icy was checked
PROWlERS PltJN Of CORREC11011 lXl) (EACt1 CORRECTIVE ACllOM SHOlLO ee CROSSmiddot COMPLETE
REFERENCEOlO THEAPPROPRIATE OEFICENCYI CATE
CopH JUN 2 l 2011 bull
LamprDAr-7middot11v
6162011 13649PM
LABORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESEIITATIVES SIGIATURE
Any dellclo~cy 1t11e111en1 tndlnD wllh 111 a11en1bull ()Oonolet bull cfellckllIC) whl1I 111 ~ijt~on may bo oxwsod from core~9 provlcn9 1111 d1temilld that ot11e1 afogu~bull provide allffiQlenl poteclion 10 lhbull patients Elltltlpl lolt nursing hollebull Ille llndinos eboO ra dlldoaablo 90 daVbull lollowlrg ht d1te or urvy whether 01 nol apion ol contcllon lbull PfOlllded for nurlna holllff ~bull algtOvt f11din91 and planbull ot corrampClion 11e dtdobullbullblbull 14 daybull tc1lltNll119 lhe dale thHe documenH are made avallablo to lhe lacllly tr defclencin are cited en a1gt91ovecf plan ol correcijon 11 requisite 10 conUnued progrem
parliclpaVon
St112587
Event I036CN11 TITLE X6)0ATE
CALIFORNIA l-poundALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL1rl
$fATEMEHT OF DEFICIENCIES ()(1) PROVIDERSUPPLtERICll CX2) MUITlPLE CONSTRUCTION ()(3) DATE SURVEY AND PlAH Of COIIRECTIOM IDElmflCAllOHNIJMSEll CO~IPLETEP
A BUlDIIIG
DWflG 02102011
NAME OF PROVlDER OR SVPPLlEII STReET ADDRESS CITY STIITEZJP cooe THE SEQUOIAS 501 PORTOLA ROAD PORTOLA VAUEY CA 94028 BAN MATEO COUNTY
1)(~)10 SIJM11RV 8lATEMENTOF OIIFICIEHClampS 10 PIIEflX EACH DEFICIENCY MUST BE PREClEDEO BV FULL PREFIX
TAO REGULATORY OR ISC IOEHTFYINCJ IHFORIMTIOlI) 1AO
Continued From pag S
Thamp lacllify staff persons ac1lon of p0$lln9 a comment on the Facebook page of a well-llnltgtWn publlc peraonaNty thanking her for being a petlenl at tho focllity ropreaents a vlotetlon of Heauh amp Safety Code 128015(a) for fallure to prevent unlawful dieclOsure of a patients medical lnforrnalOo
Pft011DflS PlAN Of CORREC110H ()(6) (EACH CORRECTIVE ACTION SHOULD BE CR0$8shy COMPIETE RffERENCEO TOTiiE NPROPRITE OUICIENCY) DATE
CD Imiddotr-H JIJN 2 l bull
10
f8r I()~ ~ middot r c
11 I
6612011 13649PMEvent 1036CN11
UBORATORY DIRECTORS Oft PROVIDERSUPPLIER AfPRESENTATMS SIGNATURE (X8) DATE
Arty dtfklency 1atefl~tendlng 111111 111 11torl1k() deno1o 1 deficllncy which the tnltitullcn may be xcuHd fbullom coneciig provldlnQ ii It detennlned that othN ufeouard I p1ovlde 1ulllclent protection to lho peni- Except lor 11111111111 hom9 lhbull findlnobull algtltNe 1edlKl0amp1b14190 day1 tollaHlng lhbull cllt cl tUNf1 wltetheror noc a plen d COffeCllon 11 provlcted for nuttfno hofflea o bove r1t1dingt and pit~ ol concUon bull re dlscoHble 14 day lotlowlno the dat 1hose documents ire mbulldbull 1v11111gt1t to Iha lampclily ti dellcIGnclu ere died u 1ppro-d pion ti cotr9tion fa ttciublte to conanued poglt11m pbullrtlctpallon
middot--------shyStato-2687 8ol8
IX~l to 8UMwRYSTATElENT OF DEFlCIENCIES 10 RlfC( (EACH OEFICIENCY MUST BE PRECEEOED BV FUU PRiFllC TAO REGULA10RI Oil LSC IPOOtrnNO INFORMATION) TAG
ConUnuad From pagbull 1
Health and Safety Code Socllon 128015 (b)(2 A clinic heaHh facility agency or hospice ahall also report any unlawful or unauthorized acceu to or use or dlsclosulB of a patients medical Information to the affected patient or the patlenrs repr91entative a1 he last known addreH no later than five business days after the unlawful or unauthorized access use or disclosure hes been detected by 1ha clinic health faclllty agency or h~pkEt
The CDPH verified that lhe faclllty informed tha affected pallent(e) or lhe pallanfs representalve(a) of Iha unlawful or unauthorized access use or dlecloaure of the paHents medical information
128015(8) Health amp Safety Code 1280 (a) A clinic health facility home heaHh agency or hospice licensed pul8uanl to Section 1204 1250 1725 or 1745 shall prevent unlawful or unaulhorized aceess lo and uae or dlscioaure of pa11ents medical lnfomatlon as defined In aubdlVaiOfI g) of SecUon 5605 of lhe Clvll Code and conslatenr with Section 130203 The deparlment after inY8sligatlon may assess an edm~ialraUve penalty for a vlolallon of this section of up to twenty-five thousand doOars ($25000) per patient whose medical lnfonnallon was unlawfully or without aulhorizalion accessed used or discloaed and up 10 aeventeen thousand five hundred dollars ($17500) per subsequent occurrence of unlawful or unauthorized access use or disclosure of that patients medical informalion For purposes of the investigation lhe department shall consider the
Health Center staff the nature of Protected Health Information (PHI) the requirement of the law to maintain strict confidentiality o PHI the procedures to follow in case a breach is discovered and the consequences ofany such breach for the facility and the stafmember(s) responsible
The Corporate Compliance Handbook was also reviewed in the In-service as was the Corporate Compliance Acknowledgment document signed in each employee file
The Administrator and the Director ofNursing Services maintain surveillance ofstaff communications - verbal and written - to assure that discussions ofPHI are not conducted publicly and thus overheard that documents are no1 exposed inappropriately during th course ofwork and are disposed
r (V I If
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH
(X1) PROVIOERISUPPLIEAALIII (lQ) MlllPLECONSTRUCTIONSTAlEMEtfT OF orflCIENCIES l(S)OAlE6URVEY IOEHTIFJCATION tIM8EIAMO PlNI OI CORRECTION COtlPlelEO
A IIVILOIHG
IIWING0~14$$ 0211012911
STREET AODRHS CITY STATE ZlP COOEIW11 Of PROVIDER OR 8UPPUER
S01 P0RTOLA ROAD PORTOLA VALLEY CA 94028 SAN MATfO COUNTYTHE SEQUOIAS
61812011 13649PM Event 1D36CN11
LABORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESENTATIVES SIGNATURE TtnE (KIi) OATE
MY deffdency 1111-Mtnl endillgwllh an aaltrtk ) dtnolea bull d1llcl1ncy which Iha i1111iulion-rn1y ~ elCUed ft0111 correcUng f)IOvldlnQ ll la deltbullrmlned lhel oher aara11111rd1 pro-ld euNlclenl protecton to lhe paUentt Ewopl fof nu11lng hom11 lhe findingbull abow re dlactoNble 90 dbullYI followlng Ille d11 of aurwy whother or not pla11 ol correction 11 pr~laquostd For nurilng homta tie eboVe lindlnga and planbull olcolaquooclion 1re dlsclonblbull 14d1y1 followlrg the dale lheH docum1n11 ere tnlda 1vall1ble lo tie rcJtty ti deficiencies aro cited an 1pprovod plan cl eorrection ls rcivltlte lo~tlnued PIOQlbullm
participation
- ---middot-- ---middot- - -shy
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENCY OfPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (XI) PROVDEMUPPLIERCllA (X2) MUITIPlE CONSTRUCTION ()(3) ()Alf SURVEY AND PlAH Of CORRECTIOlf DEHTIFICATION NUMBER
06488 A BUIDING
B WIG
COMPlETD
02102011
NAME Of PROYlOM OR SUPPLIER
THE SEQUOIAS
STREET A1l0f1E6S CllY STATE llP COOE
501 PORTOIA ROAD PORTOIA VALLlY CA 9-4028 SAN MATEO COUNTY
()(4)10 $1MMNIYSTATlMOO a OEFICIEICIEII I)
PREFIX (EACH DEFICIENCY MUST BE PRECeeDEO r(FUll PREFIX
TAO REGULATORY OI L6C lgtlHllfYING 1NfOIIWTlON) TAO
Continued From page 2 cllnlcs health fadlltys agencys or hoaplooII history of compliance with this section and other related state end federal statutes and tegulatlons themiddot exten to which the racgtty detected vloletiona and took preventative action to mnedlately corect and prevent past violations rran Rturrlng and factors outside tis control that reatrlcted the facBftys abllty to comply with lhla section The department shell have full discretion to consider all factors when detennlnlng the amount of an adrnnlstraliw penalty pun1uant to this llection
These Regulations were not met as evidenced by
Based on Interview and recortl review the facility felled to ensure the right of Resident A a well-known publlc pen1onallty to confidential treatment or health recortls when a lacilfty staff posted a comment on Realdent As Facebook page thanking her for being a patient at Iha facility This was a violation of Heatth amp Safety Code 128015(a prohfblllng unlawful disclosure of a patients medical Information Facebook is an lntampmet social networking site where people ahare Information wflh friends Some public pampn1onaliles have publle pages that can be acceased by anyone using Facebook
Findings
Review of a letter-from the facfllty dated 21311 to the Department indicated This letter Is lo inform you of a security breach with regard to certain tnformalion pertaining o a former resident of the skilled nursing facllity We were informed on
PROVIDERS PLAN OF CORRECTION (Xamp) (EACH COMECTIVE ACTION SH0Ul0 BE CROSS COMPLpoundTE
REFEREHCeD TO THE NPROPR~TE DEFICIENCY) DATE
of properly in the secure bonded shtedding facilities on premises
CDPH JUN 171011
Lampr -middotmiddot I bullbullI0 ll middot
c( i11
61612011 13641lfM
LA80RAT0RY DIRECTORmiddotS OR PROVIDERSUPPLIER REPRESpound1fTATIVES SIGNATURE TITlE (XB)DATE
Any dtllclenay 111tet11bullnl ending will an utetlsk (tdbullllotebull 11 delldency IWhlth lllbull lneijlUIJon mey be lllleused frotll oorreellllg povldlng II i$ dttannlo4lt1 ~ 1h11 other ureguenM p(Ollde autflclenl polclkgtn to the pdtnll Except or llllftlng hon1n 111bull lindlng 1bov1 r dlldoaablo to dey1 lollowlng lhbull dale ttJ or tUMy whlller or not a plen of correction r pmvlded For hurafllg llomee 1111 abo11e 11ndYIDI end pllllof correelion er dlldoaeble 14 day followlllg 12-_V ~ the dale lhue (focumenls ere t11altle ayallable lo lie 1eility Wdeflcleneltbull clktd enapprl)Yed plen ofcoroction1J requlslle lo conUnued progretll
p1rtldpaU011
Stalamp-2567 3 Of 0
Event I036CN11
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENpV OEPARTMENT OF PUBLIC HEALTH
XI) PROVIDERSUPPLIERCUA8TATEMEITT Of DEFICIENCIES (X21 IAULTIPLE CONSTRUCTION ()(3) DATE SURVEY IOENTlflCATION UMBE1ANO PlAA OF CORRECTION COMPUTED
A BUILDJHG
B VMG05586 02110(2011
STREET ADDREVS CITY STATE 21P COOE
THe SEQUOIAS 1501 PORTOLA ROAO PORTOLA VALLEY CA 94026 SAN MATEO COUNTY NAME Of PROIIIOER OR SUPPIIER
IX4) 10 $VMIWIY STA TMEHT Of DECIEHCIEO 11)
PREFl)C (EACH DElICllNCY war BE PRECEEOEO BY FVU PREFIX TAO Rf(Jl1ATORY OR ISC lllEHTFYlNG INfORIMTION) TAO
PROIIDERS PM OF CORRECTION (X6)(EACH COR~ECTM ACTION SHOULD BE CROSS COwgt~ETE
REFEAENCED TO THE APPROPRIATli DEFICIENCY) DATE
Continued From page 3
January 31 2011 lhat a (facility) employee hadposted the following on the public portion of tho former SNF (skilled nursing foelily) residentsFacebook page ____ thank you for alfowing us to care for you My staff will not forgetyour vlsll ln aecordance with Fuebook protocol a link lo lhla comment appeared lmmedlaety on the employees prlvale Facebook pege A viewer ofthat page could cUck on the common middot end be redlrecied to the former 19sidenrs Facebook page thereby leernfng the fOlmer restdenra Identity Althat point the viewer could infer thol the formor resident had been at the (fecllltys) skilled nursing fadnty baaed on the employees original corrvnent about care being provkled by the vl$II and on informa~on furnished by the employee on her Facebook page about her positron at the skilled nursing facmty Olvan the Fecebook architecture there was a polentlel disclosure lhen to persons receiving access to Iha employees private Facebook page We learned that middot~ had posted the Facebook entry on ~2010 We had the entry 1emoved on 2011 0n the basis of what was discovered we are providing written notification to the former resident In accordanca with legal requirementsshy
In a lelephone interview on 21011 at 1020am Iha Execulivo Director slaled She (Resident A) was dmitted only using her lnllials lo Identify her We
maintained her privacy the whole llmc she was here Wo didnt even uee her real namebull
RBlleW of a print-out of the posting on Resident As Facebook page revealed (Resident A) thank you
C D PH
JUN zJ 20tt
Lampr _-L middot~I Jt tv middot -bull
a
6182011 t3849PMEvent 1D36CN11
LABORATORY D1RfCT0RS OR PROllOERSUPPLIER REPRESEHTATIVES SIGNATURE TITLE (XB)OATE
Any derkh11Cy atalemant andlng lriDI an u 1tri1k ( )61no1 bull dellclency wlllcl Ille Tn1d1111on may be oxw11d rom corr1clin9 potld1ng II Ibull ltMt1rmlned 1h11 olhor 11t1guards provide tulllclonl proi~n IO Illbull p1cJn1a EXlpl to nur1lng homu he nndi)g1 above bullbullbull dlldo11bl 80 chtys ldlowlng 11o dale of wvoy 11lthethe or notbull plen or COlelttion la prowlAd Fo1 nu111110 homt1 lho above Rndlngt and p1111 01 coneltUon bullrbull dl t1011lllo I~ dayo IOllowlng the dale lhtso doc1111141111 ore mbulldbull avoiloblt ICgt lhbull taciity Ifdofoclanclo cited bullnaj)proved plan ol corocUon la requbtte 10 conlinued program partlcifMUon
501 PORTOLA ROAD PORTOLA VALLEY CA 94028 SAN MATEO COUNTY
(MJO SUMMMY 31bullm1tttr Qt- PffCIEtlCiES Q
PREFIX (EACH DEflCIEgtICY WSY BE PRECEEOED BY FOLL PREFI)(
rAG REOUIATORV CA L8C IDENTIFtNG INFORWllONJ rAG
Continued From page 4
for allowing us to care for you My sleH wll~not forget your viampIIbull It was dated 10 at 822 pm and showed the picture and full name of the lacllily employee (the Director or NUrslng) The same posting was also reflected ori the Director of Norilngo Facebook profile page under Recent Activitybull
Review of lhe facilitys 2008 Corporate CompllanC9 middot handbook for ManagerSupervisor p12 Health
Insurance Portability and Accounablllty Act (HIPM) indicated HfPM cfarlRampamp what protected heofth information can and cnnot be shared Our job Is to protect the privacy and confldenUallty of Iha residents we oerve Residents hava the right to their Protected Health lnlormatfon (PHI) PHI is anything that connects the resident to hisher Informationbull If you reveal PHI to someone who does not need to know ft you have violated a resklenta confldenllaity and have broken the law Hf PPA violations could result in Correctlve Aclon up to and Including termination11bull slrlclly prohibited to share PHI over the Internet end e-manbull
Review of the Director of Nursinge employee file ehowed her signature on a Corporate Compftance Aoknowludgment of ReGeipl and Review ol Booklet form under the statement I have reed and reviewed the (laclllty) Corporate Compliance Booklet with my Department Head or middot Supervisor and I understand my role and responsibility in adhering to Iha NCPHS Standards of Conduct The ManagerJSupervlsorbull booklet that contained the HIPM p91icy was checked
PROWlERS PltJN Of CORREC11011 lXl) (EACt1 CORRECTIVE ACllOM SHOlLO ee CROSSmiddot COMPLETE
REFERENCEOlO THEAPPROPRIATE OEFICENCYI CATE
CopH JUN 2 l 2011 bull
LamprDAr-7middot11v
6162011 13649PM
LABORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESEIITATIVES SIGIATURE
Any dellclo~cy 1t11e111en1 tndlnD wllh 111 a11en1bull ()Oonolet bull cfellckllIC) whl1I 111 ~ijt~on may bo oxwsod from core~9 provlcn9 1111 d1temilld that ot11e1 afogu~bull provide allffiQlenl poteclion 10 lhbull patients Elltltlpl lolt nursing hollebull Ille llndinos eboO ra dlldoaablo 90 daVbull lollowlrg ht d1te or urvy whether 01 nol apion ol contcllon lbull PfOlllded for nurlna holllff ~bull algtOvt f11din91 and planbull ot corrampClion 11e dtdobullbullblbull 14 daybull tc1lltNll119 lhe dale thHe documenH are made avallablo to lhe lacllly tr defclencin are cited en a1gt91ovecf plan ol correcijon 11 requisite 10 conUnued progrem
parliclpaVon
St112587
Event I036CN11 TITLE X6)0ATE
CALIFORNIA l-poundALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL1rl
$fATEMEHT OF DEFICIENCIES ()(1) PROVIDERSUPPLtERICll CX2) MUITlPLE CONSTRUCTION ()(3) DATE SURVEY AND PlAH Of COIIRECTIOM IDElmflCAllOHNIJMSEll CO~IPLETEP
A BUlDIIIG
DWflG 02102011
NAME OF PROVlDER OR SVPPLlEII STReET ADDRESS CITY STIITEZJP cooe THE SEQUOIAS 501 PORTOLA ROAD PORTOLA VAUEY CA 94028 BAN MATEO COUNTY
1)(~)10 SIJM11RV 8lATEMENTOF OIIFICIEHClampS 10 PIIEflX EACH DEFICIENCY MUST BE PREClEDEO BV FULL PREFIX
TAO REGULATORY OR ISC IOEHTFYINCJ IHFORIMTIOlI) 1AO
Continued From pag S
Thamp lacllify staff persons ac1lon of p0$lln9 a comment on the Facebook page of a well-llnltgtWn publlc peraonaNty thanking her for being a petlenl at tho focllity ropreaents a vlotetlon of Heauh amp Safety Code 128015(a) for fallure to prevent unlawful dieclOsure of a patients medical lnforrnalOo
Pft011DflS PlAN Of CORREC110H ()(6) (EACH CORRECTIVE ACTION SHOULD BE CR0$8shy COMPIETE RffERENCEO TOTiiE NPROPRITE OUICIENCY) DATE
CD Imiddotr-H JIJN 2 l bull
10
f8r I()~ ~ middot r c
11 I
6612011 13649PMEvent 1036CN11
UBORATORY DIRECTORS Oft PROVIDERSUPPLIER AfPRESENTATMS SIGNATURE (X8) DATE
Arty dtfklency 1atefl~tendlng 111111 111 11torl1k() deno1o 1 deficllncy which the tnltitullcn may be xcuHd fbullom coneciig provldlnQ ii It detennlned that othN ufeouard I p1ovlde 1ulllclent protection to lho peni- Except lor 11111111111 hom9 lhbull findlnobull algtltNe 1edlKl0amp1b14190 day1 tollaHlng lhbull cllt cl tUNf1 wltetheror noc a plen d COffeCllon 11 provlcted for nuttfno hofflea o bove r1t1dingt and pit~ ol concUon bull re dlscoHble 14 day lotlowlno the dat 1hose documents ire mbulldbull 1v11111gt1t to Iha lampclily ti dellcIGnclu ere died u 1ppro-d pion ti cotr9tion fa ttciublte to conanued poglt11m pbullrtlctpallon
middot--------shyStato-2687 8ol8
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENCY OfPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (XI) PROVDEMUPPLIERCllA (X2) MUITIPlE CONSTRUCTION ()(3) ()Alf SURVEY AND PlAH Of CORRECTIOlf DEHTIFICATION NUMBER
06488 A BUIDING
B WIG
COMPlETD
02102011
NAME Of PROYlOM OR SUPPLIER
THE SEQUOIAS
STREET A1l0f1E6S CllY STATE llP COOE
501 PORTOIA ROAD PORTOIA VALLlY CA 9-4028 SAN MATEO COUNTY
()(4)10 $1MMNIYSTATlMOO a OEFICIEICIEII I)
PREFIX (EACH DEFICIENCY MUST BE PRECeeDEO r(FUll PREFIX
TAO REGULATORY OI L6C lgtlHllfYING 1NfOIIWTlON) TAO
Continued From page 2 cllnlcs health fadlltys agencys or hoaplooII history of compliance with this section and other related state end federal statutes and tegulatlons themiddot exten to which the racgtty detected vloletiona and took preventative action to mnedlately corect and prevent past violations rran Rturrlng and factors outside tis control that reatrlcted the facBftys abllty to comply with lhla section The department shell have full discretion to consider all factors when detennlnlng the amount of an adrnnlstraliw penalty pun1uant to this llection
These Regulations were not met as evidenced by
Based on Interview and recortl review the facility felled to ensure the right of Resident A a well-known publlc pen1onallty to confidential treatment or health recortls when a lacilfty staff posted a comment on Realdent As Facebook page thanking her for being a patient at Iha facility This was a violation of Heatth amp Safety Code 128015(a prohfblllng unlawful disclosure of a patients medical Information Facebook is an lntampmet social networking site where people ahare Information wflh friends Some public pampn1onaliles have publle pages that can be acceased by anyone using Facebook
Findings
Review of a letter-from the facfllty dated 21311 to the Department indicated This letter Is lo inform you of a security breach with regard to certain tnformalion pertaining o a former resident of the skilled nursing facllity We were informed on
PROVIDERS PLAN OF CORRECTION (Xamp) (EACH COMECTIVE ACTION SH0Ul0 BE CROSS COMPLpoundTE
REFEREHCeD TO THE NPROPR~TE DEFICIENCY) DATE
of properly in the secure bonded shtedding facilities on premises
CDPH JUN 171011
Lampr -middotmiddot I bullbullI0 ll middot
c( i11
61612011 13641lfM
LA80RAT0RY DIRECTORmiddotS OR PROVIDERSUPPLIER REPRESpound1fTATIVES SIGNATURE TITlE (XB)DATE
Any dtllclenay 111tet11bullnl ending will an utetlsk (tdbullllotebull 11 delldency IWhlth lllbull lneijlUIJon mey be lllleused frotll oorreellllg povldlng II i$ dttannlo4lt1 ~ 1h11 other ureguenM p(Ollde autflclenl polclkgtn to the pdtnll Except or llllftlng hon1n 111bull lindlng 1bov1 r dlldoaablo to dey1 lollowlng lhbull dale ttJ or tUMy whlller or not a plen of correction r pmvlded For hurafllg llomee 1111 abo11e 11ndYIDI end pllllof correelion er dlldoaeble 14 day followlllg 12-_V ~ the dale lhue (focumenls ere t11altle ayallable lo lie 1eility Wdeflcleneltbull clktd enapprl)Yed plen ofcoroction1J requlslle lo conUnued progretll
p1rtldpaU011
Stalamp-2567 3 Of 0
Event I036CN11
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENpV OEPARTMENT OF PUBLIC HEALTH
XI) PROVIDERSUPPLIERCUA8TATEMEITT Of DEFICIENCIES (X21 IAULTIPLE CONSTRUCTION ()(3) DATE SURVEY IOENTlflCATION UMBE1ANO PlAA OF CORRECTION COMPUTED
A BUILDJHG
B VMG05586 02110(2011
STREET ADDREVS CITY STATE 21P COOE
THe SEQUOIAS 1501 PORTOLA ROAO PORTOLA VALLEY CA 94026 SAN MATEO COUNTY NAME Of PROIIIOER OR SUPPIIER
IX4) 10 $VMIWIY STA TMEHT Of DECIEHCIEO 11)
PREFl)C (EACH DElICllNCY war BE PRECEEOEO BY FVU PREFIX TAO Rf(Jl1ATORY OR ISC lllEHTFYlNG INfORIMTION) TAO
PROIIDERS PM OF CORRECTION (X6)(EACH COR~ECTM ACTION SHOULD BE CROSS COwgt~ETE
REFEAENCED TO THE APPROPRIATli DEFICIENCY) DATE
Continued From page 3
January 31 2011 lhat a (facility) employee hadposted the following on the public portion of tho former SNF (skilled nursing foelily) residentsFacebook page ____ thank you for alfowing us to care for you My staff will not forgetyour vlsll ln aecordance with Fuebook protocol a link lo lhla comment appeared lmmedlaety on the employees prlvale Facebook pege A viewer ofthat page could cUck on the common middot end be redlrecied to the former 19sidenrs Facebook page thereby leernfng the fOlmer restdenra Identity Althat point the viewer could infer thol the formor resident had been at the (fecllltys) skilled nursing fadnty baaed on the employees original corrvnent about care being provkled by the vl$II and on informa~on furnished by the employee on her Facebook page about her positron at the skilled nursing facmty Olvan the Fecebook architecture there was a polentlel disclosure lhen to persons receiving access to Iha employees private Facebook page We learned that middot~ had posted the Facebook entry on ~2010 We had the entry 1emoved on 2011 0n the basis of what was discovered we are providing written notification to the former resident In accordanca with legal requirementsshy
In a lelephone interview on 21011 at 1020am Iha Execulivo Director slaled She (Resident A) was dmitted only using her lnllials lo Identify her We
maintained her privacy the whole llmc she was here Wo didnt even uee her real namebull
RBlleW of a print-out of the posting on Resident As Facebook page revealed (Resident A) thank you
C D PH
JUN zJ 20tt
Lampr _-L middot~I Jt tv middot -bull
a
6182011 t3849PMEvent 1D36CN11
LABORATORY D1RfCT0RS OR PROllOERSUPPLIER REPRESEHTATIVES SIGNATURE TITLE (XB)OATE
Any derkh11Cy atalemant andlng lriDI an u 1tri1k ( )61no1 bull dellclency wlllcl Ille Tn1d1111on may be oxw11d rom corr1clin9 potld1ng II Ibull ltMt1rmlned 1h11 olhor 11t1guards provide tulllclonl proi~n IO Illbull p1cJn1a EXlpl to nur1lng homu he nndi)g1 above bullbullbull dlldo11bl 80 chtys ldlowlng 11o dale of wvoy 11lthethe or notbull plen or COlelttion la prowlAd Fo1 nu111110 homt1 lho above Rndlngt and p1111 01 coneltUon bullrbull dl t1011lllo I~ dayo IOllowlng the dale lhtso doc1111141111 ore mbulldbull avoiloblt ICgt lhbull taciity Ifdofoclanclo cited bullnaj)proved plan ol corocUon la requbtte 10 conlinued program partlcifMUon
501 PORTOLA ROAD PORTOLA VALLEY CA 94028 SAN MATEO COUNTY
(MJO SUMMMY 31bullm1tttr Qt- PffCIEtlCiES Q
PREFIX (EACH DEflCIEgtICY WSY BE PRECEEOED BY FOLL PREFI)(
rAG REOUIATORV CA L8C IDENTIFtNG INFORWllONJ rAG
Continued From page 4
for allowing us to care for you My sleH wll~not forget your viampIIbull It was dated 10 at 822 pm and showed the picture and full name of the lacllily employee (the Director or NUrslng) The same posting was also reflected ori the Director of Norilngo Facebook profile page under Recent Activitybull
Review of lhe facilitys 2008 Corporate CompllanC9 middot handbook for ManagerSupervisor p12 Health
Insurance Portability and Accounablllty Act (HIPM) indicated HfPM cfarlRampamp what protected heofth information can and cnnot be shared Our job Is to protect the privacy and confldenUallty of Iha residents we oerve Residents hava the right to their Protected Health lnlormatfon (PHI) PHI is anything that connects the resident to hisher Informationbull If you reveal PHI to someone who does not need to know ft you have violated a resklenta confldenllaity and have broken the law Hf PPA violations could result in Correctlve Aclon up to and Including termination11bull slrlclly prohibited to share PHI over the Internet end e-manbull
Review of the Director of Nursinge employee file ehowed her signature on a Corporate Compftance Aoknowludgment of ReGeipl and Review ol Booklet form under the statement I have reed and reviewed the (laclllty) Corporate Compliance Booklet with my Department Head or middot Supervisor and I understand my role and responsibility in adhering to Iha NCPHS Standards of Conduct The ManagerJSupervlsorbull booklet that contained the HIPM p91icy was checked
PROWlERS PltJN Of CORREC11011 lXl) (EACt1 CORRECTIVE ACllOM SHOlLO ee CROSSmiddot COMPLETE
REFERENCEOlO THEAPPROPRIATE OEFICENCYI CATE
CopH JUN 2 l 2011 bull
LamprDAr-7middot11v
6162011 13649PM
LABORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESEIITATIVES SIGIATURE
Any dellclo~cy 1t11e111en1 tndlnD wllh 111 a11en1bull ()Oonolet bull cfellckllIC) whl1I 111 ~ijt~on may bo oxwsod from core~9 provlcn9 1111 d1temilld that ot11e1 afogu~bull provide allffiQlenl poteclion 10 lhbull patients Elltltlpl lolt nursing hollebull Ille llndinos eboO ra dlldoaablo 90 daVbull lollowlrg ht d1te or urvy whether 01 nol apion ol contcllon lbull PfOlllded for nurlna holllff ~bull algtOvt f11din91 and planbull ot corrampClion 11e dtdobullbullblbull 14 daybull tc1lltNll119 lhe dale thHe documenH are made avallablo to lhe lacllly tr defclencin are cited en a1gt91ovecf plan ol correcijon 11 requisite 10 conUnued progrem
parliclpaVon
St112587
Event I036CN11 TITLE X6)0ATE
CALIFORNIA l-poundALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL1rl
$fATEMEHT OF DEFICIENCIES ()(1) PROVIDERSUPPLtERICll CX2) MUITlPLE CONSTRUCTION ()(3) DATE SURVEY AND PlAH Of COIIRECTIOM IDElmflCAllOHNIJMSEll CO~IPLETEP
A BUlDIIIG
DWflG 02102011
NAME OF PROVlDER OR SVPPLlEII STReET ADDRESS CITY STIITEZJP cooe THE SEQUOIAS 501 PORTOLA ROAD PORTOLA VAUEY CA 94028 BAN MATEO COUNTY
1)(~)10 SIJM11RV 8lATEMENTOF OIIFICIEHClampS 10 PIIEflX EACH DEFICIENCY MUST BE PREClEDEO BV FULL PREFIX
TAO REGULATORY OR ISC IOEHTFYINCJ IHFORIMTIOlI) 1AO
Continued From pag S
Thamp lacllify staff persons ac1lon of p0$lln9 a comment on the Facebook page of a well-llnltgtWn publlc peraonaNty thanking her for being a petlenl at tho focllity ropreaents a vlotetlon of Heauh amp Safety Code 128015(a) for fallure to prevent unlawful dieclOsure of a patients medical lnforrnalOo
Pft011DflS PlAN Of CORREC110H ()(6) (EACH CORRECTIVE ACTION SHOULD BE CR0$8shy COMPIETE RffERENCEO TOTiiE NPROPRITE OUICIENCY) DATE
CD Imiddotr-H JIJN 2 l bull
10
f8r I()~ ~ middot r c
11 I
6612011 13649PMEvent 1036CN11
UBORATORY DIRECTORS Oft PROVIDERSUPPLIER AfPRESENTATMS SIGNATURE (X8) DATE
Arty dtfklency 1atefl~tendlng 111111 111 11torl1k() deno1o 1 deficllncy which the tnltitullcn may be xcuHd fbullom coneciig provldlnQ ii It detennlned that othN ufeouard I p1ovlde 1ulllclent protection to lho peni- Except lor 11111111111 hom9 lhbull findlnobull algtltNe 1edlKl0amp1b14190 day1 tollaHlng lhbull cllt cl tUNf1 wltetheror noc a plen d COffeCllon 11 provlcted for nuttfno hofflea o bove r1t1dingt and pit~ ol concUon bull re dlscoHble 14 day lotlowlno the dat 1hose documents ire mbulldbull 1v11111gt1t to Iha lampclily ti dellcIGnclu ere died u 1ppro-d pion ti cotr9tion fa ttciublte to conanued poglt11m pbullrtlctpallon
middot--------shyStato-2687 8ol8
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENpV OEPARTMENT OF PUBLIC HEALTH
XI) PROVIDERSUPPLIERCUA8TATEMEITT Of DEFICIENCIES (X21 IAULTIPLE CONSTRUCTION ()(3) DATE SURVEY IOENTlflCATION UMBE1ANO PlAA OF CORRECTION COMPUTED
A BUILDJHG
B VMG05586 02110(2011
STREET ADDREVS CITY STATE 21P COOE
THe SEQUOIAS 1501 PORTOLA ROAO PORTOLA VALLEY CA 94026 SAN MATEO COUNTY NAME Of PROIIIOER OR SUPPIIER
IX4) 10 $VMIWIY STA TMEHT Of DECIEHCIEO 11)
PREFl)C (EACH DElICllNCY war BE PRECEEOEO BY FVU PREFIX TAO Rf(Jl1ATORY OR ISC lllEHTFYlNG INfORIMTION) TAO
PROIIDERS PM OF CORRECTION (X6)(EACH COR~ECTM ACTION SHOULD BE CROSS COwgt~ETE
REFEAENCED TO THE APPROPRIATli DEFICIENCY) DATE
Continued From page 3
January 31 2011 lhat a (facility) employee hadposted the following on the public portion of tho former SNF (skilled nursing foelily) residentsFacebook page ____ thank you for alfowing us to care for you My staff will not forgetyour vlsll ln aecordance with Fuebook protocol a link lo lhla comment appeared lmmedlaety on the employees prlvale Facebook pege A viewer ofthat page could cUck on the common middot end be redlrecied to the former 19sidenrs Facebook page thereby leernfng the fOlmer restdenra Identity Althat point the viewer could infer thol the formor resident had been at the (fecllltys) skilled nursing fadnty baaed on the employees original corrvnent about care being provkled by the vl$II and on informa~on furnished by the employee on her Facebook page about her positron at the skilled nursing facmty Olvan the Fecebook architecture there was a polentlel disclosure lhen to persons receiving access to Iha employees private Facebook page We learned that middot~ had posted the Facebook entry on ~2010 We had the entry 1emoved on 2011 0n the basis of what was discovered we are providing written notification to the former resident In accordanca with legal requirementsshy
In a lelephone interview on 21011 at 1020am Iha Execulivo Director slaled She (Resident A) was dmitted only using her lnllials lo Identify her We
maintained her privacy the whole llmc she was here Wo didnt even uee her real namebull
RBlleW of a print-out of the posting on Resident As Facebook page revealed (Resident A) thank you
C D PH
JUN zJ 20tt
Lampr _-L middot~I Jt tv middot -bull
a
6182011 t3849PMEvent 1D36CN11
LABORATORY D1RfCT0RS OR PROllOERSUPPLIER REPRESEHTATIVES SIGNATURE TITLE (XB)OATE
Any derkh11Cy atalemant andlng lriDI an u 1tri1k ( )61no1 bull dellclency wlllcl Ille Tn1d1111on may be oxw11d rom corr1clin9 potld1ng II Ibull ltMt1rmlned 1h11 olhor 11t1guards provide tulllclonl proi~n IO Illbull p1cJn1a EXlpl to nur1lng homu he nndi)g1 above bullbullbull dlldo11bl 80 chtys ldlowlng 11o dale of wvoy 11lthethe or notbull plen or COlelttion la prowlAd Fo1 nu111110 homt1 lho above Rndlngt and p1111 01 coneltUon bullrbull dl t1011lllo I~ dayo IOllowlng the dale lhtso doc1111141111 ore mbulldbull avoiloblt ICgt lhbull taciity Ifdofoclanclo cited bullnaj)proved plan ol corocUon la requbtte 10 conlinued program partlcifMUon
501 PORTOLA ROAD PORTOLA VALLEY CA 94028 SAN MATEO COUNTY
(MJO SUMMMY 31bullm1tttr Qt- PffCIEtlCiES Q
PREFIX (EACH DEflCIEgtICY WSY BE PRECEEOED BY FOLL PREFI)(
rAG REOUIATORV CA L8C IDENTIFtNG INFORWllONJ rAG
Continued From page 4
for allowing us to care for you My sleH wll~not forget your viampIIbull It was dated 10 at 822 pm and showed the picture and full name of the lacllily employee (the Director or NUrslng) The same posting was also reflected ori the Director of Norilngo Facebook profile page under Recent Activitybull
Review of lhe facilitys 2008 Corporate CompllanC9 middot handbook for ManagerSupervisor p12 Health
Insurance Portability and Accounablllty Act (HIPM) indicated HfPM cfarlRampamp what protected heofth information can and cnnot be shared Our job Is to protect the privacy and confldenUallty of Iha residents we oerve Residents hava the right to their Protected Health lnlormatfon (PHI) PHI is anything that connects the resident to hisher Informationbull If you reveal PHI to someone who does not need to know ft you have violated a resklenta confldenllaity and have broken the law Hf PPA violations could result in Correctlve Aclon up to and Including termination11bull slrlclly prohibited to share PHI over the Internet end e-manbull
Review of the Director of Nursinge employee file ehowed her signature on a Corporate Compftance Aoknowludgment of ReGeipl and Review ol Booklet form under the statement I have reed and reviewed the (laclllty) Corporate Compliance Booklet with my Department Head or middot Supervisor and I understand my role and responsibility in adhering to Iha NCPHS Standards of Conduct The ManagerJSupervlsorbull booklet that contained the HIPM p91icy was checked
PROWlERS PltJN Of CORREC11011 lXl) (EACt1 CORRECTIVE ACllOM SHOlLO ee CROSSmiddot COMPLETE
REFERENCEOlO THEAPPROPRIATE OEFICENCYI CATE
CopH JUN 2 l 2011 bull
LamprDAr-7middot11v
6162011 13649PM
LABORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESEIITATIVES SIGIATURE
Any dellclo~cy 1t11e111en1 tndlnD wllh 111 a11en1bull ()Oonolet bull cfellckllIC) whl1I 111 ~ijt~on may bo oxwsod from core~9 provlcn9 1111 d1temilld that ot11e1 afogu~bull provide allffiQlenl poteclion 10 lhbull patients Elltltlpl lolt nursing hollebull Ille llndinos eboO ra dlldoaablo 90 daVbull lollowlrg ht d1te or urvy whether 01 nol apion ol contcllon lbull PfOlllded for nurlna holllff ~bull algtOvt f11din91 and planbull ot corrampClion 11e dtdobullbullblbull 14 daybull tc1lltNll119 lhe dale thHe documenH are made avallablo to lhe lacllly tr defclencin are cited en a1gt91ovecf plan ol correcijon 11 requisite 10 conUnued progrem
parliclpaVon
St112587
Event I036CN11 TITLE X6)0ATE
CALIFORNIA l-poundALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL1rl
$fATEMEHT OF DEFICIENCIES ()(1) PROVIDERSUPPLtERICll CX2) MUITlPLE CONSTRUCTION ()(3) DATE SURVEY AND PlAH Of COIIRECTIOM IDElmflCAllOHNIJMSEll CO~IPLETEP
A BUlDIIIG
DWflG 02102011
NAME OF PROVlDER OR SVPPLlEII STReET ADDRESS CITY STIITEZJP cooe THE SEQUOIAS 501 PORTOLA ROAD PORTOLA VAUEY CA 94028 BAN MATEO COUNTY
1)(~)10 SIJM11RV 8lATEMENTOF OIIFICIEHClampS 10 PIIEflX EACH DEFICIENCY MUST BE PREClEDEO BV FULL PREFIX
TAO REGULATORY OR ISC IOEHTFYINCJ IHFORIMTIOlI) 1AO
Continued From pag S
Thamp lacllify staff persons ac1lon of p0$lln9 a comment on the Facebook page of a well-llnltgtWn publlc peraonaNty thanking her for being a petlenl at tho focllity ropreaents a vlotetlon of Heauh amp Safety Code 128015(a) for fallure to prevent unlawful dieclOsure of a patients medical lnforrnalOo
Pft011DflS PlAN Of CORREC110H ()(6) (EACH CORRECTIVE ACTION SHOULD BE CR0$8shy COMPIETE RffERENCEO TOTiiE NPROPRITE OUICIENCY) DATE
CD Imiddotr-H JIJN 2 l bull
10
f8r I()~ ~ middot r c
11 I
6612011 13649PMEvent 1036CN11
UBORATORY DIRECTORS Oft PROVIDERSUPPLIER AfPRESENTATMS SIGNATURE (X8) DATE
Arty dtfklency 1atefl~tendlng 111111 111 11torl1k() deno1o 1 deficllncy which the tnltitullcn may be xcuHd fbullom coneciig provldlnQ ii It detennlned that othN ufeouard I p1ovlde 1ulllclent protection to lho peni- Except lor 11111111111 hom9 lhbull findlnobull algtltNe 1edlKl0amp1b14190 day1 tollaHlng lhbull cllt cl tUNf1 wltetheror noc a plen d COffeCllon 11 provlcted for nuttfno hofflea o bove r1t1dingt and pit~ ol concUon bull re dlscoHble 14 day lotlowlno the dat 1hose documents ire mbulldbull 1v11111gt1t to Iha lampclily ti dellcIGnclu ere died u 1ppro-d pion ti cotr9tion fa ttciublte to conanued poglt11m pbullrtlctpallon
middot--------shyStato-2687 8ol8
CALIFORNIA HEALTH ANO HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTtt
501 PORTOLA ROAD PORTOLA VALLEY CA 94028 SAN MATEO COUNTY
(MJO SUMMMY 31bullm1tttr Qt- PffCIEtlCiES Q
PREFIX (EACH DEflCIEgtICY WSY BE PRECEEOED BY FOLL PREFI)(
rAG REOUIATORV CA L8C IDENTIFtNG INFORWllONJ rAG
Continued From page 4
for allowing us to care for you My sleH wll~not forget your viampIIbull It was dated 10 at 822 pm and showed the picture and full name of the lacllily employee (the Director or NUrslng) The same posting was also reflected ori the Director of Norilngo Facebook profile page under Recent Activitybull
Review of lhe facilitys 2008 Corporate CompllanC9 middot handbook for ManagerSupervisor p12 Health
Insurance Portability and Accounablllty Act (HIPM) indicated HfPM cfarlRampamp what protected heofth information can and cnnot be shared Our job Is to protect the privacy and confldenUallty of Iha residents we oerve Residents hava the right to their Protected Health lnlormatfon (PHI) PHI is anything that connects the resident to hisher Informationbull If you reveal PHI to someone who does not need to know ft you have violated a resklenta confldenllaity and have broken the law Hf PPA violations could result in Correctlve Aclon up to and Including termination11bull slrlclly prohibited to share PHI over the Internet end e-manbull
Review of the Director of Nursinge employee file ehowed her signature on a Corporate Compftance Aoknowludgment of ReGeipl and Review ol Booklet form under the statement I have reed and reviewed the (laclllty) Corporate Compliance Booklet with my Department Head or middot Supervisor and I understand my role and responsibility in adhering to Iha NCPHS Standards of Conduct The ManagerJSupervlsorbull booklet that contained the HIPM p91icy was checked
PROWlERS PltJN Of CORREC11011 lXl) (EACt1 CORRECTIVE ACllOM SHOlLO ee CROSSmiddot COMPLETE
REFERENCEOlO THEAPPROPRIATE OEFICENCYI CATE
CopH JUN 2 l 2011 bull
LamprDAr-7middot11v
6162011 13649PM
LABORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESEIITATIVES SIGIATURE
Any dellclo~cy 1t11e111en1 tndlnD wllh 111 a11en1bull ()Oonolet bull cfellckllIC) whl1I 111 ~ijt~on may bo oxwsod from core~9 provlcn9 1111 d1temilld that ot11e1 afogu~bull provide allffiQlenl poteclion 10 lhbull patients Elltltlpl lolt nursing hollebull Ille llndinos eboO ra dlldoaablo 90 daVbull lollowlrg ht d1te or urvy whether 01 nol apion ol contcllon lbull PfOlllded for nurlna holllff ~bull algtOvt f11din91 and planbull ot corrampClion 11e dtdobullbullblbull 14 daybull tc1lltNll119 lhe dale thHe documenH are made avallablo to lhe lacllly tr defclencin are cited en a1gt91ovecf plan ol correcijon 11 requisite 10 conUnued progrem
parliclpaVon
St112587
Event I036CN11 TITLE X6)0ATE
CALIFORNIA l-poundALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL1rl
$fATEMEHT OF DEFICIENCIES ()(1) PROVIDERSUPPLtERICll CX2) MUITlPLE CONSTRUCTION ()(3) DATE SURVEY AND PlAH Of COIIRECTIOM IDElmflCAllOHNIJMSEll CO~IPLETEP
A BUlDIIIG
DWflG 02102011
NAME OF PROVlDER OR SVPPLlEII STReET ADDRESS CITY STIITEZJP cooe THE SEQUOIAS 501 PORTOLA ROAD PORTOLA VAUEY CA 94028 BAN MATEO COUNTY
1)(~)10 SIJM11RV 8lATEMENTOF OIIFICIEHClampS 10 PIIEflX EACH DEFICIENCY MUST BE PREClEDEO BV FULL PREFIX
TAO REGULATORY OR ISC IOEHTFYINCJ IHFORIMTIOlI) 1AO
Continued From pag S
Thamp lacllify staff persons ac1lon of p0$lln9 a comment on the Facebook page of a well-llnltgtWn publlc peraonaNty thanking her for being a petlenl at tho focllity ropreaents a vlotetlon of Heauh amp Safety Code 128015(a) for fallure to prevent unlawful dieclOsure of a patients medical lnforrnalOo
Pft011DflS PlAN Of CORREC110H ()(6) (EACH CORRECTIVE ACTION SHOULD BE CR0$8shy COMPIETE RffERENCEO TOTiiE NPROPRITE OUICIENCY) DATE
CD Imiddotr-H JIJN 2 l bull
10
f8r I()~ ~ middot r c
11 I
6612011 13649PMEvent 1036CN11
UBORATORY DIRECTORS Oft PROVIDERSUPPLIER AfPRESENTATMS SIGNATURE (X8) DATE
Arty dtfklency 1atefl~tendlng 111111 111 11torl1k() deno1o 1 deficllncy which the tnltitullcn may be xcuHd fbullom coneciig provldlnQ ii It detennlned that othN ufeouard I p1ovlde 1ulllclent protection to lho peni- Except lor 11111111111 hom9 lhbull findlnobull algtltNe 1edlKl0amp1b14190 day1 tollaHlng lhbull cllt cl tUNf1 wltetheror noc a plen d COffeCllon 11 provlcted for nuttfno hofflea o bove r1t1dingt and pit~ ol concUon bull re dlscoHble 14 day lotlowlno the dat 1hose documents ire mbulldbull 1v11111gt1t to Iha lampclily ti dellcIGnclu ere died u 1ppro-d pion ti cotr9tion fa ttciublte to conanued poglt11m pbullrtlctpallon
middot--------shyStato-2687 8ol8
CALIFORNIA l-poundALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL1rl
$fATEMEHT OF DEFICIENCIES ()(1) PROVIDERSUPPLtERICll CX2) MUITlPLE CONSTRUCTION ()(3) DATE SURVEY AND PlAH Of COIIRECTIOM IDElmflCAllOHNIJMSEll CO~IPLETEP
A BUlDIIIG
DWflG 02102011
NAME OF PROVlDER OR SVPPLlEII STReET ADDRESS CITY STIITEZJP cooe THE SEQUOIAS 501 PORTOLA ROAD PORTOLA VAUEY CA 94028 BAN MATEO COUNTY
1)(~)10 SIJM11RV 8lATEMENTOF OIIFICIEHClampS 10 PIIEflX EACH DEFICIENCY MUST BE PREClEDEO BV FULL PREFIX
TAO REGULATORY OR ISC IOEHTFYINCJ IHFORIMTIOlI) 1AO
Continued From pag S
Thamp lacllify staff persons ac1lon of p0$lln9 a comment on the Facebook page of a well-llnltgtWn publlc peraonaNty thanking her for being a petlenl at tho focllity ropreaents a vlotetlon of Heauh amp Safety Code 128015(a) for fallure to prevent unlawful dieclOsure of a patients medical lnforrnalOo
Pft011DflS PlAN Of CORREC110H ()(6) (EACH CORRECTIVE ACTION SHOULD BE CR0$8shy COMPIETE RffERENCEO TOTiiE NPROPRITE OUICIENCY) DATE
CD Imiddotr-H JIJN 2 l bull
10
f8r I()~ ~ middot r c
11 I
6612011 13649PMEvent 1036CN11
UBORATORY DIRECTORS Oft PROVIDERSUPPLIER AfPRESENTATMS SIGNATURE (X8) DATE
Arty dtfklency 1atefl~tendlng 111111 111 11torl1k() deno1o 1 deficllncy which the tnltitullcn may be xcuHd fbullom coneciig provldlnQ ii It detennlned that othN ufeouard I p1ovlde 1ulllclent protection to lho peni- Except lor 11111111111 hom9 lhbull findlnobull algtltNe 1edlKl0amp1b14190 day1 tollaHlng lhbull cllt cl tUNf1 wltetheror noc a plen d COffeCllon 11 provlcted for nuttfno hofflea o bove r1t1dingt and pit~ ol concUon bull re dlscoHble 14 day lotlowlno the dat 1hose documents ire mbulldbull 1v11111gt1t to Iha lampclily ti dellcIGnclu ere died u 1ppro-d pion ti cotr9tion fa ttciublte to conanued poglt11m pbullrtlctpallon
