I I
of Public visit
Complaint CA00200378
Representing the
event investigated findings
Health A clinic hospice
unauthorized patients subd v sion and
I
or disclosed hundred occurrence use information
tnformed
Event 10YRJL 11
J r-cCtJ i9LLO
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH g v STATEMENT OF DEFICIENCIES PltOVIOERISUPPLIERICUA
AND PLAN OF CORRECTION IOENTIFlA liON NUMBER
050180
(X1) (X1)11ULTIPLE CONSTRUCTION (XJ) DATE SURVH
COMPLETED
A BUILDING
B MNG 062912010 I NAhiE OF PROVIDER OR SUPPLIER
John Muir Medical Canter- Walnut Creek
Campus
STREET ADDRESS CITY STATE ZlP CODE
1601 YGNACIO VALLEY ROAD WALNUT CREEK CA 94598 CONTRA COST A
COUNTY
(X4)1D SUhiWRY STATEUENT OF OEFIGIEHCIES
(EACH DEFICIENCY MUST BE PRECEEDEO BY FULL REGUtATORY OR LSC IDENTIFYING INFORWTION)
m
The following reflects the findings of the Department Health during a complaintlbreaGh event
Intake Number
bull Substantiated
Department of Public Health
HFEN
The inspection was limited to the specific facility
and does not represent the
of a full inspection of the facility
ood Safety Code Section 128015(8)
health facility home health agency Olt
licensed pu rsu ant to Section 1204 1250
1725 0lt 1745 shall prevent unlawful 0lt
access to aod ooe or d isclosu re of
medical informat ion d efined
i i (g) of Section 5605 of the Cilil Code
consisten t with Section 130203 The
department a tfer investigation may assess eo administrative pe nalty for a violation of this sect ion
of up to twenty-five thousand dollars ($25000) per
pat ient whose medical infermation was unlawfully
without authoriza t ion accessed used 0lt aod to seventeen thousand f1ve
dollars ($17500) subsequ ent of unlawful 0lt u nauthorized access
0lt disclosure of that patients medical
The hospital detected the breacn 00 81109 and
the Depa rtment within the requ ired five
business day time period
73012010
OR PROVIDERSUPPLIER REPRESEHTAnVES SIGNATURE
PROIlOERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS
REFERENCED TO THE APPROPRIATE DEFICIENCY) PREFIX PREFIX
COioiPLETE
om
Plan of Correction Response for Complain II CA00200378
To ensure cDrreclion was accomplished both temporarily and p ermanen tly for each the following actions have been taken
1 Patient go and Wife notified via US mail
of incident and offered credit monitoring protection service
81709
Responsible Person VP Chief Compliance and Privacy Officer
2 Implemented new process for management of the Emergency
Departmen t Patient Information Sheets which requires that clerks immediately scan and shred informat ion sheets upon receipt from the patient This new proces s will provide additional safeguards to further protect patien t information from unauthorized access use or discJosu re
99og
Responsible Person Office Manager Emergency Departmen t and Director Emergency Department 915109 amp
91709
3 Reviewed and educated Clerical Staff on neYJ process Responsible Person Office Manager Emergency Department
91044AM
TJTIE (XB) DATE
ant ending wilt1 an Hlerisk () deiIOUs a defiCiency which lha lnstHulloll may be excused rrcm conecllng prcvkllng il is dete1111ined that other salegua s provide suffident pralecllon D the pallenls Excaptfor nunlng homea the findings above are diulosa lil iKI days following Ole dalo ct SUMY whether or not a plan of correcOOn is provldld For nuning horn$ the above findings and plans or coiEICkln are disclo8able 14 days following 1t1111 dale these documents are made eveila e 1o he facility 1r dllllclsnles are cited an appro ed plan or correclion Ia requisite lo continued pnrem
parliclpabon
5tata-2567 1 of 5
j
---------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot---------------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot-----
CALIFORNIA HEAllr AND HUMAN SERVICES A3ENCY
DEPARTMENT Of PVSUC HEALTH
STAEiolEkTOF OEFIC-lgtCIES 0(1) PROIIDERbullSIJPPUEIClgtli (lt2) loULf1PLE CONSTRUCTION (XJ) 01 TE SURWY i00 HA (pound CQRtJCQltl I JEt lFICAflON tU 9ER CltmlllThJ
A_ euJbullOINC
BMNG 0611Ui2010
MC OF PPOYIOEIlt OR SfifUER STREETAOJRESS CIT STATI- ZIP CODE
John Muir Medlesl CentermiddotWalnut CrMk 1601 YGNACIO VALLE( ROAD WALNUT CREEK CA 9468$ COHTRA COSTA
-middot COUNTY
txbullliD SUMWltY STA T OF OEFICENCIES
EACi lEFIIECY US BE PRECeuroeuroCED BY FiJLL ilEGIO-m_y OR eSC liJ Et41 fYIIIC NfORIIATION)
Continued From paga 1
B01$ed on oCoervOJiion lnteMew coed nowiew I hospfal raed tc $Sfeguard the informalion in IPallen SOs 1nedical record by faling to protect the
Eneqerny Department Patient lnformelion Sheet
resufting 1n 1he ide1tity theft of patient and his wife
Findings
Oc 5120110 Assistant Compli ance Officer
p esented review the hospital Privacy Breach fnwstlgation Form fhe br each n the
confidentiality ot Patient 90s medi cal info rrJaUon The Privacy Breach Investigation Form dated 81709 inc lu ded the Incident Report Fo eight pages document showed hat Palie1t
90s wife called the hosptal on 81109 lo report lhflt sha hd been the oJictim of idert(ity thet lhal the person 1amp5pOMibamp (Of this crirramp hgt Of he possesson at the time of arrest heaOh
informfllion from the hospital wich she used o
commit fraud
Further review showed that P tient 90 wife brought Patient 9tllo ED iEilergtrtt Department e 01 p t gtr of there
I
gisration orocess he wife middot- the
hoepttal term Nted [rloep tal narre) Emergency CWpartrnent Patient Information Sheei and provided Patent 90 and Cf ( was tho primltry insured) pampl$011amp hformllJo inclJdng t full
na E$- datQs ol birth address end social security
numbers Pa1ier 90was admitted arnl later
discharged The wife tlto eeited lh within a few
weeks after Patinl 90s clschage from
PIOVIOEASAN OF COIFiCTOIW (- ) (ACtgtcORREC1-EACT ON SH-U O SE C OSS- COMgtE_ E
IltElEiICNC10 TO THE APPRO FiAT5 lEFCIENC IltEHX PREFIX I
fAG
Continue Phm of Correction Response for Complaint CA0020037$
4 lmpmiddoteme11 rew process for closJre Of B9110 podmiddot by cenca staff members wilhmiddot1 the Emerge cy DeoartmeL t-ew
process requires that prlomiddot to a p00closure all paUenl re a led cocumentatior nor--paient inforrraon sheets wll be p1yscally moved by he aoprcpfiale cerk lc =-oo 3 Which 1s always cccupied by a derical staff nemcer_ Tt-is 1ew processw further safegJard oatie11 hfurmalcn maintained by cmiddotefieal staffWJhin the Errergrocy Departner
Responsible Perton Office Manager
Erlergexy Deoartment
5 Jaily eiiew concucted three times per
day (eacl shift) in a 24-hcur period ro ampW20i0
ensure Cleflos complmnce hilh (on-gorgtg
cepartmeot procedure for scanning and for a periOd
shredding patienl1nformaUon sheeis d 30 C3j5)
Review o continue for a period of 30
days to ensJre 100 compliarce with department procedure Appropriate
acliar to be taken 11 accordance with review lindmgs Review to be re-evaJated after 30 days to ascertalr wheher moniortng will be conllnJeltJ discontinued ot revised
Rl$JgtOO$ibl P8rsQO Office Marbullaer Emergency Department and lead CleO Emergency Department
1i lho
I
81errti0YR3L 1 TITLE (X6)WTE
An defklency ttablmerri erdlgtJ Jib bull - ut IW 11 de a dllfoilttey tkh IM irlllttllbon may boo ud lrorn auwf pmWinl A daiSfTineo trial oltllaquo VlfeJMJIIt proVIde bullIJI)Imiddotenl p m 1M plliefW fotlliiAI9 hciM4 1M fWmgt bullgtwoo AalampqgtJa(IID to dllfi diowig bull dam QligtNuy wlgtelherlaquo rct11 rllill or em _ lllaquoriltkd For lliiiWlP lhit flrntmnamp iillll plmllof regn- ere 4JtimlttgtQ j-4 leloewirll 1t1a date teso doerotfltr ao mado ayenQbe b le aQty_ lf tile an a pill d COIledion s requilamp tn llfued am PifcipampIXfl
I I
I
Slllta-2567 3 ol 5
C OUFORNA HEALTH ANO HUMAN SERVICES AGENCY
DEPARTMENT Of PUBLIC HEALTH
STATpoundlfrNT OF DECLNCiCamp X1) igtRt1 DElJSVPP IltIlltUI tn) IIJLiiPlE CON1illtUC10h 1XJ) WI--pound SUlVEY lhD PtiN OF COfmtiOtJ IOENWC_tT[JN NIJtER GDMPLEXD
A 8UI DNS 050180 I WI G ()eztf2010
NAME OF fPfYJJliR Ult SJPPLfR CRCET ADDkt$$ CiTY gtirt liP CODE John tlulr Medgtta Centermiddot Walnut C--1 Hl01 YGNACIO VALLEY ROAO WALNUT CREEl CA 945913 CONTlA COSTA
Campu COUNTY
(X4) 10 PRF
TA
SIMMAIiJ S ATEMENT OF 0poundFCIHICIpoundS
(EACH CtfiCIfrNCY_IJST Bf lliECl0pound0 flY FLl
RO(iJLJnli Oflt l SC ID(NTI ilfltG ltltfDEW 101
PflEFIX
TAG
Continued FrQm page 2 I hosplal he discovered person was using infonratum to open credit accotrrs make purch01ses nee nOIITeuro The person responsice
1 W S sted aod woo fo nd have i S arre u c
middot DOSsessicn tlCCUTlent the hospital whic
i shlt was usmg to open cp thes e accouns and i I WhiCh was later denb ied as be1rg the Errergency
Deoa ment Pate1 lnformton Sheel
Review on 52010 of te Emergency Depanment middot Paherr lrformallon Sheet Paflent 9051owed
thai 1n nluded Patient 90s pr o ected health
informaNm ircluding rame age gender social
security numoebull address physician account
rmber rredieal recor d nJmber admission date employment statw acd employers address
alw contained 1forna01 about Patient 90 wifeuro i ncludmg helt b name age ma middotta slatus ad ress social seunty nurrber heah
IISoranre mformalon The nciderl Report Form furher showed that le
II Emergency Departmer Pat1errt lormatl01 Sheer
WltS b y registrat101 staff the tene ol
h
pafenrs adnissiof obtain t e nane date of birth address social securit1bull nllmber and insurance informahon aoo it was filled cot by the patient or a family memberlaget of the patient Toe
sheet was lhlt Re9 istmiddota 1gt1 de the middot lnancal COIIIl selor to ente the patients data 1llO i
the hospitals data system a1d was then handed i off to the lead derk who woJk then place it into a
basket that sa directly behind the lead clerks desk I was the le3d clerks job to assure lhe accuracy of the informaton and scan the sheet middotnto
I
Event IOYR3L11 113012010 91044AM
AUORATORY ClilteuroCTORS OR PROVIDEltVSUPPt IER RERESENTAflVIS SONATURE
I
i
Pflt)VDEiiS P _All Of CORECTION
tACM CC ECTIVE 1CIO SHOLJ EIE CROSS
lttTFFEIltCEOTOTHE AP ltOPRltkTii OP CltllCY)
(M)COFlETE
OAE
I
An1 ltlltleiltocy ltgttatement erid -an llllenbullk ( ) derm6$ aerteot which he nnuhn -ay be exltltrod rom eoltecting pUltidwg 41$ ctlt tetmiled lhal olgtOlt sl dllltdgt provide JIIlmml p l on to the IXh tlt Eepl bullor nJUll19 IltOIWl too findbullngs abeyen( yenC sabl 90 dly$ cqwitlJIte date ol survty wgtelercr net a pan m COt 11 ptwltQett FOIIIIffliiG hcrgtet e above hings lld pWamp or 10nectkm ant dillclowble 1 diit5 lcllcwrg u dale hlllil doou nt ant made available kl tte alt IIY If debull-ic gte e11cd an app111red plan rf co-rectioo i roQtii51W c ltltgtnlnued u middotam PAAbullpa cn
lt21 MUL Tl~LE COfSt~uCTiOt
NAME CF PROVIDER Cll SUPPl iEll
--middotmiddotmiddot-------------------------------------------------------------------
CALIFORNIA HEALIH AND HUMAN SERVgtCES AGWCY DEPARTMENT OF PJKIC HEAc rH
S1ATEME1T Dt DEFICIENIf$ (X1l PPcentVDEltSc-PPlEltiClA ( 11 JAT[ SvRVCt iD PIAN OF COltRltTION bullOamphTIbullmiddotCA middotON NWJBER COMLTED
A BUILDING
0501811 B W1NG 1292010
STREET ADORtSS CITY STATE I COD
John Muir Medital CM1er- Walnut Crook 1601 YGNACIO VALLEY ROAD WALNUT CREEK CA 94593 CONTRA COSTA
Campus COUNTY
M IJ SUMIIAIY SlATEAtJH OF lEfiIEIJCfS (l CH OEfiCilNCY MUST bpound FfltrCrrDO flr ltl l RFGcJLATORY OR lSC 0E TIYmiddotNGgt IH MATIOIIJ
Ff10VII)[ S PLAN 7 CCRRECTON f(5) PRU-IX f-C-i COlHftTIIf AOION SHOUlD BE CROSSmiddot COIWLPE
REFEREiCfO TO Hlf AFPROPRIltTf OHICLNC1) OATE
Continued From paglt l
lhe aief1ls rectYd A ccorJmiddotg to he rctdenl i Repcli the ETiergelcy Deparllllerl Patient
nknnallon Shffitl CChid sil in he amp-et for vp lo two days An ED 1ead clerk and a ED t1ansporter
i (staff assigned the duties of transporting patients
withm the hosp ital) W1Ht kwesligaled by the hOspital and found to be relatelt to lgte person
respoiSbe for lle identity heft The mc1dent was
still uider iWestgabon by a police task force
Observation en 6130110 at 10lt30 am_ of he Emergency Departrret the OeSeuroCeuro of ED
Manage showed hree areu ca ed pods tat
Were desk area s wth a glass wall fl 111e front of the
desk Entry to 11e cd area was by way of ar1 open
walkway at e11ner eoo cf the desk Ttere was no
I door cr Pa1ilicn Pod 3 had a desk facing the glass
wall had ccrrpuler termin als and chairs flttCif19 the g la ss wa1 and a co vnter behind the de$1lt with a
basket holding completed admitf1ng papers en It
The EO Manager stated the lead cerk wor ked at
Pod 3
The hospital POlicy tbulltko PHImiddot Pnvacy PrlttciCfls
Uses and DlsclosiES of Proleded 1-ealth
lnformalcn revsed 9G7 aXl lteveWed on 5120110 slated workforce rrem rs (eTiployee vclunteers
ctlleS )lysicans and ohar alliiXl health
professionals whle I)CVdti9 cae may net UStgt or
disclose PHI in a manner bullncotlssten wilh federal
and slate Jaw$ aod regulatons The policy
inslrucieltl staff 10 make sure ttlat medical
middotinformation tat identifies he p atient is ltepl private
i e-cept as the palienl authcnzes or as laws requhlt
IX oermit The p licy further inslvcted
i i
j o
Event iDYRjl11 730200 91044AM
IlTLE (XgtI OATE
Any ooticgtenoy $llemtml ntlmiJ w1gt an a llrw n wnola 11 trlt-middot011Cf whch rte on$ 1 1ion may be excused rom cmrRMg prtWitllt1 middott middot tleettYIIcent tNH omr sttQlt111amp ptevtle $All litgt I gtrJcentCho w h cuen5 Ebullcem lorlvrsig hon1e the 11ndogs abOve Mgt dbull lltgt5 bkl C days llogt9 he daHl
af yen hihl m net a pan Ol ltXWltteJO $ Pf0gt1iW Fw w mg Wflpound lh above londi9 and pillgt$ ol correc ot are chdoSble 14 day hgt hgt9
1-e dale lh e dnttrenb are lldll avulllle tcent tl1$ hlQIIy I deiOiltmC$ are lied an appro ed pa ol WJeeJO $ bulle iJmiddot$ te 10 o IJlaquo prosrgttm
gta1ocopgtUo
73012010
CAUORNIA HFAl TH AND HUMAN SERVICFS AGENCY
DEPARTMENT OF PUBLIC HEAlTH
$ 1TEMfNT JFDEIIt MgtlS XT) PROIiDERISlJPPIIERCL( x Mlltll e CONSRCON pgt) DATE 5UflgtEV
AltD PlAN CF COlllOCgtQgti iOfl lrCATiOt NJIltBFR COoPlffFD A 3JL0iNG
050100 3 WigtC 062912010
N-YF CW OvllER OR SJFPUI STRC - AI)JRESS CrY GT TE l P CODE John Muir Meikll CantO Imiddot Walnut CrQek 1f(l1 YGNACIO V4LLEY ROAD WAlNUT CREEK CA 94598 CONTRA COSTA
CarnpU$ COUNTY
X4)10 PiiEFI
TAG
S t1MARY OnYMIENTO OCFICifN(IES (Efo(li O FCiENbullV IJ$7 IE PRtCEEDED W FL
lfCVATOltr OR lScent llflIFYImiddotKgt NIOilMAlQo
Continued From page 4
Reasolable precaJtb s must be a- en to
rrniMire the chance of inadvertent disdosure of PHI to d1viduals wo tio not have a Jeed lo know middot
iREF X
TAC
PIltOVOERS PLAl OF CCR EC710N
I ACH COR ECtfCACT ON StiOIIU a CROSS-
Rgt(RfNCEO fO THpound 1PPROJgtCIAft OE VfNCY)
15) COJ ETE
Dl1
i
i
I
i
I I
i
Event IDYR3L 11 9 044AM
LAB RATOOY DIRECTORS OR fROvltlERSUfPUER REPRESENTATlVES SIGNAlURE TITLE Zfi) CPTE
Agty dllltcim1q stafemliN(IdiJIg wrh ao ijSem 1bull1 ltlltllfnl a dehrllmcy hdgt hlt in iluten may l8 excu ed I row ccnectm1 proHdlng n m riebummed lhlll o er ampafegusnhi piClt tie gtcJffi ienl prolecboo In te pabllnt_ E=eplorron Jg homgt hefnltfrg above am ltil ble 00 CBJ fuowiCoQ It ltlaW Q trtiJ1 whetter Of IQ a piJin JI orrectlim is wov for nuraing ht11$ 1e lilllole lindlfl91 ltgtd plans o corroctiOf alo lisdosable H aay JulQWill tie dalE lhew docurombullgt are rrade ampva1labW ttl he lacility 1 1ooendes ruq Cliae an tpprQffld p-all ot CllllKl Pn tamp requisill W WIMJCltl progr
ooerocpallttlll
j
---------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot---------------middotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddotmiddot-----
CALIFORNIA HEAllr AND HUMAN SERVICES A3ENCY
DEPARTMENT Of PVSUC HEALTH
STAEiolEkTOF OEFIC-lgtCIES 0(1) PROIIDERbullSIJPPUEIClgtli (lt2) loULf1PLE CONSTRUCTION (XJ) 01 TE SURWY i00 HA (pound CQRtJCQltl I JEt lFICAflON tU 9ER CltmlllThJ
A_ euJbullOINC
BMNG 0611Ui2010
MC OF PPOYIOEIlt OR SfifUER STREETAOJRESS CIT STATI- ZIP CODE
John Muir Medlesl CentermiddotWalnut CrMk 1601 YGNACIO VALLE( ROAD WALNUT CREEK CA 9468$ COHTRA COSTA
-middot COUNTY
txbullliD SUMWltY STA T OF OEFICENCIES
EACi lEFIIECY US BE PRECeuroeuroCED BY FiJLL ilEGIO-m_y OR eSC liJ Et41 fYIIIC NfORIIATION)
Continued From paga 1
B01$ed on oCoervOJiion lnteMew coed nowiew I hospfal raed tc $Sfeguard the informalion in IPallen SOs 1nedical record by faling to protect the
Eneqerny Department Patient lnformelion Sheet
resufting 1n 1he ide1tity theft of patient and his wife
Findings
Oc 5120110 Assistant Compli ance Officer
p esented review the hospital Privacy Breach fnwstlgation Form fhe br each n the
confidentiality ot Patient 90s medi cal info rrJaUon The Privacy Breach Investigation Form dated 81709 inc lu ded the Incident Report Fo eight pages document showed hat Palie1t
90s wife called the hosptal on 81109 lo report lhflt sha hd been the oJictim of idert(ity thet lhal the person 1amp5pOMibamp (Of this crirramp hgt Of he possesson at the time of arrest heaOh
informfllion from the hospital wich she used o
commit fraud
Further review showed that P tient 90 wife brought Patient 9tllo ED iEilergtrtt Department e 01 p t gtr of there
I
gisration orocess he wife middot- the
hoepttal term Nted [rloep tal narre) Emergency CWpartrnent Patient Information Sheei and provided Patent 90 and Cf ( was tho primltry insured) pampl$011amp hformllJo inclJdng t full
na E$- datQs ol birth address end social security
numbers Pa1ier 90was admitted arnl later
discharged The wife tlto eeited lh within a few
weeks after Patinl 90s clschage from
PIOVIOEASAN OF COIFiCTOIW (- ) (ACtgtcORREC1-EACT ON SH-U O SE C OSS- COMgtE_ E
IltElEiICNC10 TO THE APPRO FiAT5 lEFCIENC IltEHX PREFIX I
fAG
Continue Phm of Correction Response for Complaint CA0020037$
4 lmpmiddoteme11 rew process for closJre Of B9110 podmiddot by cenca staff members wilhmiddot1 the Emerge cy DeoartmeL t-ew
process requires that prlomiddot to a p00closure all paUenl re a led cocumentatior nor--paient inforrraon sheets wll be p1yscally moved by he aoprcpfiale cerk lc =-oo 3 Which 1s always cccupied by a derical staff nemcer_ Tt-is 1ew processw further safegJard oatie11 hfurmalcn maintained by cmiddotefieal staffWJhin the Errergrocy Departner
Responsible Perton Office Manager
Erlergexy Deoartment
5 Jaily eiiew concucted three times per
day (eacl shift) in a 24-hcur period ro ampW20i0
ensure Cleflos complmnce hilh (on-gorgtg
cepartmeot procedure for scanning and for a periOd
shredding patienl1nformaUon sheeis d 30 C3j5)
Review o continue for a period of 30
days to ensJre 100 compliarce with department procedure Appropriate
acliar to be taken 11 accordance with review lindmgs Review to be re-evaJated after 30 days to ascertalr wheher moniortng will be conllnJeltJ discontinued ot revised
Rl$JgtOO$ibl P8rsQO Office Marbullaer Emergency Department and lead CleO Emergency Department
1i lho
I
81errti0YR3L 1 TITLE (X6)WTE
An defklency ttablmerri erdlgtJ Jib bull - ut IW 11 de a dllfoilttey tkh IM irlllttllbon may boo ud lrorn auwf pmWinl A daiSfTineo trial oltllaquo VlfeJMJIIt proVIde bullIJI)Imiddotenl p m 1M plliefW fotlliiAI9 hciM4 1M fWmgt bullgtwoo AalampqgtJa(IID to dllfi diowig bull dam QligtNuy wlgtelherlaquo rct11 rllill or em _ lllaquoriltkd For lliiiWlP lhit flrntmnamp iillll plmllof regn- ere 4JtimlttgtQ j-4 leloewirll 1t1a date teso doerotfltr ao mado ayenQbe b le aQty_ lf tile an a pill d COIledion s requilamp tn llfued am PifcipampIXfl
I I
I
Slllta-2567 3 ol 5
C OUFORNA HEALTH ANO HUMAN SERVICES AGENCY
DEPARTMENT Of PUBLIC HEALTH
STATpoundlfrNT OF DECLNCiCamp X1) igtRt1 DElJSVPP IltIlltUI tn) IIJLiiPlE CON1illtUC10h 1XJ) WI--pound SUlVEY lhD PtiN OF COfmtiOtJ IOENWC_tT[JN NIJtER GDMPLEXD
A 8UI DNS 050180 I WI G ()eztf2010
NAME OF fPfYJJliR Ult SJPPLfR CRCET ADDkt$$ CiTY gtirt liP CODE John tlulr Medgtta Centermiddot Walnut C--1 Hl01 YGNACIO VALLEY ROAO WALNUT CREEl CA 945913 CONTlA COSTA
Campu COUNTY
(X4) 10 PRF
TA
SIMMAIiJ S ATEMENT OF 0poundFCIHICIpoundS
(EACH CtfiCIfrNCY_IJST Bf lliECl0pound0 flY FLl
RO(iJLJnli Oflt l SC ID(NTI ilfltG ltltfDEW 101
PflEFIX
TAG
Continued FrQm page 2 I hosplal he discovered person was using infonratum to open credit accotrrs make purch01ses nee nOIITeuro The person responsice
1 W S sted aod woo fo nd have i S arre u c
middot DOSsessicn tlCCUTlent the hospital whic
i shlt was usmg to open cp thes e accouns and i I WhiCh was later denb ied as be1rg the Errergency
Deoa ment Pate1 lnformton Sheel
Review on 52010 of te Emergency Depanment middot Paherr lrformallon Sheet Paflent 9051owed
thai 1n nluded Patient 90s pr o ected health
informaNm ircluding rame age gender social
security numoebull address physician account
rmber rredieal recor d nJmber admission date employment statw acd employers address
alw contained 1forna01 about Patient 90 wifeuro i ncludmg helt b name age ma middotta slatus ad ress social seunty nurrber heah
IISoranre mformalon The nciderl Report Form furher showed that le
II Emergency Departmer Pat1errt lormatl01 Sheer
WltS b y registrat101 staff the tene ol
h
pafenrs adnissiof obtain t e nane date of birth address social securit1bull nllmber and insurance informahon aoo it was filled cot by the patient or a family memberlaget of the patient Toe
sheet was lhlt Re9 istmiddota 1gt1 de the middot lnancal COIIIl selor to ente the patients data 1llO i
the hospitals data system a1d was then handed i off to the lead derk who woJk then place it into a
basket that sa directly behind the lead clerks desk I was the le3d clerks job to assure lhe accuracy of the informaton and scan the sheet middotnto
I
Event IOYR3L11 113012010 91044AM
AUORATORY ClilteuroCTORS OR PROVIDEltVSUPPt IER RERESENTAflVIS SONATURE
I
i
Pflt)VDEiiS P _All Of CORECTION
tACM CC ECTIVE 1CIO SHOLJ EIE CROSS
lttTFFEIltCEOTOTHE AP ltOPRltkTii OP CltllCY)
(M)COFlETE
OAE
I
An1 ltlltleiltocy ltgttatement erid -an llllenbullk ( ) derm6$ aerteot which he nnuhn -ay be exltltrod rom eoltecting pUltidwg 41$ ctlt tetmiled lhal olgtOlt sl dllltdgt provide JIIlmml p l on to the IXh tlt Eepl bullor nJUll19 IltOIWl too findbullngs abeyen( yenC sabl 90 dly$ cqwitlJIte date ol survty wgtelercr net a pan m COt 11 ptwltQett FOIIIIffliiG hcrgtet e above hings lld pWamp or 10nectkm ant dillclowble 1 diit5 lcllcwrg u dale hlllil doou nt ant made available kl tte alt IIY If debull-ic gte e11cd an app111red plan rf co-rectioo i roQtii51W c ltltgtnlnued u middotam PAAbullpa cn
lt21 MUL Tl~LE COfSt~uCTiOt
NAME CF PROVIDER Cll SUPPl iEll
--middotmiddotmiddot-------------------------------------------------------------------
CALIFORNIA HEALIH AND HUMAN SERVgtCES AGWCY DEPARTMENT OF PJKIC HEAc rH
S1ATEME1T Dt DEFICIENIf$ (X1l PPcentVDEltSc-PPlEltiClA ( 11 JAT[ SvRVCt iD PIAN OF COltRltTION bullOamphTIbullmiddotCA middotON NWJBER COMLTED
A BUILDING
0501811 B W1NG 1292010
STREET ADORtSS CITY STATE I COD
John Muir Medital CM1er- Walnut Crook 1601 YGNACIO VALLEY ROAD WALNUT CREEK CA 94593 CONTRA COSTA
Campus COUNTY
M IJ SUMIIAIY SlATEAtJH OF lEfiIEIJCfS (l CH OEfiCilNCY MUST bpound FfltrCrrDO flr ltl l RFGcJLATORY OR lSC 0E TIYmiddotNGgt IH MATIOIIJ
Ff10VII)[ S PLAN 7 CCRRECTON f(5) PRU-IX f-C-i COlHftTIIf AOION SHOUlD BE CROSSmiddot COIWLPE
REFEREiCfO TO Hlf AFPROPRIltTf OHICLNC1) OATE
Continued From paglt l
lhe aief1ls rectYd A ccorJmiddotg to he rctdenl i Repcli the ETiergelcy Deparllllerl Patient
nknnallon Shffitl CChid sil in he amp-et for vp lo two days An ED 1ead clerk and a ED t1ansporter
i (staff assigned the duties of transporting patients
withm the hosp ital) W1Ht kwesligaled by the hOspital and found to be relatelt to lgte person
respoiSbe for lle identity heft The mc1dent was
still uider iWestgabon by a police task force
Observation en 6130110 at 10lt30 am_ of he Emergency Departrret the OeSeuroCeuro of ED
Manage showed hree areu ca ed pods tat
Were desk area s wth a glass wall fl 111e front of the
desk Entry to 11e cd area was by way of ar1 open
walkway at e11ner eoo cf the desk Ttere was no
I door cr Pa1ilicn Pod 3 had a desk facing the glass
wall had ccrrpuler termin als and chairs flttCif19 the g la ss wa1 and a co vnter behind the de$1lt with a
basket holding completed admitf1ng papers en It
The EO Manager stated the lead cerk wor ked at
Pod 3
The hospital POlicy tbulltko PHImiddot Pnvacy PrlttciCfls
Uses and DlsclosiES of Proleded 1-ealth
lnformalcn revsed 9G7 aXl lteveWed on 5120110 slated workforce rrem rs (eTiployee vclunteers
ctlleS )lysicans and ohar alliiXl health
professionals whle I)CVdti9 cae may net UStgt or
disclose PHI in a manner bullncotlssten wilh federal
and slate Jaw$ aod regulatons The policy
inslrucieltl staff 10 make sure ttlat medical
middotinformation tat identifies he p atient is ltepl private
i e-cept as the palienl authcnzes or as laws requhlt
IX oermit The p licy further inslvcted
i i
j o
Event iDYRjl11 730200 91044AM
IlTLE (XgtI OATE
Any ooticgtenoy $llemtml ntlmiJ w1gt an a llrw n wnola 11 trlt-middot011Cf whch rte on$ 1 1ion may be excused rom cmrRMg prtWitllt1 middott middot tleettYIIcent tNH omr sttQlt111amp ptevtle $All litgt I gtrJcentCho w h cuen5 Ebullcem lorlvrsig hon1e the 11ndogs abOve Mgt dbull lltgt5 bkl C days llogt9 he daHl
af yen hihl m net a pan Ol ltXWltteJO $ Pf0gt1iW Fw w mg Wflpound lh above londi9 and pillgt$ ol correc ot are chdoSble 14 day hgt hgt9
1-e dale lh e dnttrenb are lldll avulllle tcent tl1$ hlQIIy I deiOiltmC$ are lied an appro ed pa ol WJeeJO $ bulle iJmiddot$ te 10 o IJlaquo prosrgttm
gta1ocopgtUo
73012010
CAUORNIA HFAl TH AND HUMAN SERVICFS AGENCY
DEPARTMENT OF PUBLIC HEAlTH
$ 1TEMfNT JFDEIIt MgtlS XT) PROIiDERISlJPPIIERCL( x Mlltll e CONSRCON pgt) DATE 5UflgtEV
AltD PlAN CF COlllOCgtQgti iOfl lrCATiOt NJIltBFR COoPlffFD A 3JL0iNG
050100 3 WigtC 062912010
N-YF CW OvllER OR SJFPUI STRC - AI)JRESS CrY GT TE l P CODE John Muir Meikll CantO Imiddot Walnut CrQek 1f(l1 YGNACIO V4LLEY ROAD WAlNUT CREEK CA 94598 CONTRA COSTA
CarnpU$ COUNTY
X4)10 PiiEFI
TAG
S t1MARY OnYMIENTO OCFICifN(IES (Efo(li O FCiENbullV IJ$7 IE PRtCEEDED W FL
lfCVATOltr OR lScent llflIFYImiddotKgt NIOilMAlQo
Continued From page 4
Reasolable precaJtb s must be a- en to
rrniMire the chance of inadvertent disdosure of PHI to d1viduals wo tio not have a Jeed lo know middot
iREF X
TAC
PIltOVOERS PLAl OF CCR EC710N
I ACH COR ECtfCACT ON StiOIIU a CROSS-
Rgt(RfNCEO fO THpound 1PPROJgtCIAft OE VfNCY)
15) COJ ETE
Dl1
i
i
I
i
I I
i
Event IDYR3L 11 9 044AM
LAB RATOOY DIRECTORS OR fROvltlERSUfPUER REPRESENTATlVES SIGNAlURE TITLE Zfi) CPTE
Agty dllltcim1q stafemliN(IdiJIg wrh ao ijSem 1bull1 ltlltllfnl a dehrllmcy hdgt hlt in iluten may l8 excu ed I row ccnectm1 proHdlng n m riebummed lhlll o er ampafegusnhi piClt tie gtcJffi ienl prolecboo In te pabllnt_ E=eplorron Jg homgt hefnltfrg above am ltil ble 00 CBJ fuowiCoQ It ltlaW Q trtiJ1 whetter Of IQ a piJin JI orrectlim is wov for nuraing ht11$ 1e lilllole lindlfl91 ltgtd plans o corroctiOf alo lisdosable H aay JulQWill tie dalE lhew docurombullgt are rrade ampva1labW ttl he lacility 1 1ooendes ruq Cliae an tpprQffld p-all ot CllllKl Pn tamp requisill W WIMJCltl progr
ooerocpallttlll
I I
I
Slllta-2567 3 ol 5
C OUFORNA HEALTH ANO HUMAN SERVICES AGENCY
DEPARTMENT Of PUBLIC HEALTH
STATpoundlfrNT OF DECLNCiCamp X1) igtRt1 DElJSVPP IltIlltUI tn) IIJLiiPlE CON1illtUC10h 1XJ) WI--pound SUlVEY lhD PtiN OF COfmtiOtJ IOENWC_tT[JN NIJtER GDMPLEXD
A 8UI DNS 050180 I WI G ()eztf2010
NAME OF fPfYJJliR Ult SJPPLfR CRCET ADDkt$$ CiTY gtirt liP CODE John tlulr Medgtta Centermiddot Walnut C--1 Hl01 YGNACIO VALLEY ROAO WALNUT CREEl CA 945913 CONTlA COSTA
Campu COUNTY
(X4) 10 PRF
TA
SIMMAIiJ S ATEMENT OF 0poundFCIHICIpoundS
(EACH CtfiCIfrNCY_IJST Bf lliECl0pound0 flY FLl
RO(iJLJnli Oflt l SC ID(NTI ilfltG ltltfDEW 101
PflEFIX
TAG
Continued FrQm page 2 I hosplal he discovered person was using infonratum to open credit accotrrs make purch01ses nee nOIITeuro The person responsice
1 W S sted aod woo fo nd have i S arre u c
middot DOSsessicn tlCCUTlent the hospital whic
i shlt was usmg to open cp thes e accouns and i I WhiCh was later denb ied as be1rg the Errergency
Deoa ment Pate1 lnformton Sheel
Review on 52010 of te Emergency Depanment middot Paherr lrformallon Sheet Paflent 9051owed
thai 1n nluded Patient 90s pr o ected health
informaNm ircluding rame age gender social
security numoebull address physician account
rmber rredieal recor d nJmber admission date employment statw acd employers address
alw contained 1forna01 about Patient 90 wifeuro i ncludmg helt b name age ma middotta slatus ad ress social seunty nurrber heah
IISoranre mformalon The nciderl Report Form furher showed that le
II Emergency Departmer Pat1errt lormatl01 Sheer
WltS b y registrat101 staff the tene ol
h
pafenrs adnissiof obtain t e nane date of birth address social securit1bull nllmber and insurance informahon aoo it was filled cot by the patient or a family memberlaget of the patient Toe
sheet was lhlt Re9 istmiddota 1gt1 de the middot lnancal COIIIl selor to ente the patients data 1llO i
the hospitals data system a1d was then handed i off to the lead derk who woJk then place it into a
basket that sa directly behind the lead clerks desk I was the le3d clerks job to assure lhe accuracy of the informaton and scan the sheet middotnto
I
Event IOYR3L11 113012010 91044AM
AUORATORY ClilteuroCTORS OR PROVIDEltVSUPPt IER RERESENTAflVIS SONATURE
I
i
Pflt)VDEiiS P _All Of CORECTION
tACM CC ECTIVE 1CIO SHOLJ EIE CROSS
lttTFFEIltCEOTOTHE AP ltOPRltkTii OP CltllCY)
(M)COFlETE
OAE
I
An1 ltlltleiltocy ltgttatement erid -an llllenbullk ( ) derm6$ aerteot which he nnuhn -ay be exltltrod rom eoltecting pUltidwg 41$ ctlt tetmiled lhal olgtOlt sl dllltdgt provide JIIlmml p l on to the IXh tlt Eepl bullor nJUll19 IltOIWl too findbullngs abeyen( yenC sabl 90 dly$ cqwitlJIte date ol survty wgtelercr net a pan m COt 11 ptwltQett FOIIIIffliiG hcrgtet e above hings lld pWamp or 10nectkm ant dillclowble 1 diit5 lcllcwrg u dale hlllil doou nt ant made available kl tte alt IIY If debull-ic gte e11cd an app111red plan rf co-rectioo i roQtii51W c ltltgtnlnued u middotam PAAbullpa cn
lt21 MUL Tl~LE COfSt~uCTiOt
NAME CF PROVIDER Cll SUPPl iEll
--middotmiddotmiddot-------------------------------------------------------------------
CALIFORNIA HEALIH AND HUMAN SERVgtCES AGWCY DEPARTMENT OF PJKIC HEAc rH
S1ATEME1T Dt DEFICIENIf$ (X1l PPcentVDEltSc-PPlEltiClA ( 11 JAT[ SvRVCt iD PIAN OF COltRltTION bullOamphTIbullmiddotCA middotON NWJBER COMLTED
A BUILDING
0501811 B W1NG 1292010
STREET ADORtSS CITY STATE I COD
John Muir Medital CM1er- Walnut Crook 1601 YGNACIO VALLEY ROAD WALNUT CREEK CA 94593 CONTRA COSTA
Campus COUNTY
M IJ SUMIIAIY SlATEAtJH OF lEfiIEIJCfS (l CH OEfiCilNCY MUST bpound FfltrCrrDO flr ltl l RFGcJLATORY OR lSC 0E TIYmiddotNGgt IH MATIOIIJ
Ff10VII)[ S PLAN 7 CCRRECTON f(5) PRU-IX f-C-i COlHftTIIf AOION SHOUlD BE CROSSmiddot COIWLPE
REFEREiCfO TO Hlf AFPROPRIltTf OHICLNC1) OATE
Continued From paglt l
lhe aief1ls rectYd A ccorJmiddotg to he rctdenl i Repcli the ETiergelcy Deparllllerl Patient
nknnallon Shffitl CChid sil in he amp-et for vp lo two days An ED 1ead clerk and a ED t1ansporter
i (staff assigned the duties of transporting patients
withm the hosp ital) W1Ht kwesligaled by the hOspital and found to be relatelt to lgte person
respoiSbe for lle identity heft The mc1dent was
still uider iWestgabon by a police task force
Observation en 6130110 at 10lt30 am_ of he Emergency Departrret the OeSeuroCeuro of ED
Manage showed hree areu ca ed pods tat
Were desk area s wth a glass wall fl 111e front of the
desk Entry to 11e cd area was by way of ar1 open
walkway at e11ner eoo cf the desk Ttere was no
I door cr Pa1ilicn Pod 3 had a desk facing the glass
wall had ccrrpuler termin als and chairs flttCif19 the g la ss wa1 and a co vnter behind the de$1lt with a
basket holding completed admitf1ng papers en It
The EO Manager stated the lead cerk wor ked at
Pod 3
The hospital POlicy tbulltko PHImiddot Pnvacy PrlttciCfls
Uses and DlsclosiES of Proleded 1-ealth
lnformalcn revsed 9G7 aXl lteveWed on 5120110 slated workforce rrem rs (eTiployee vclunteers
ctlleS )lysicans and ohar alliiXl health
professionals whle I)CVdti9 cae may net UStgt or
disclose PHI in a manner bullncotlssten wilh federal
and slate Jaw$ aod regulatons The policy
inslrucieltl staff 10 make sure ttlat medical
middotinformation tat identifies he p atient is ltepl private
i e-cept as the palienl authcnzes or as laws requhlt
IX oermit The p licy further inslvcted
i i
j o
Event iDYRjl11 730200 91044AM
IlTLE (XgtI OATE
Any ooticgtenoy $llemtml ntlmiJ w1gt an a llrw n wnola 11 trlt-middot011Cf whch rte on$ 1 1ion may be excused rom cmrRMg prtWitllt1 middott middot tleettYIIcent tNH omr sttQlt111amp ptevtle $All litgt I gtrJcentCho w h cuen5 Ebullcem lorlvrsig hon1e the 11ndogs abOve Mgt dbull lltgt5 bkl C days llogt9 he daHl
af yen hihl m net a pan Ol ltXWltteJO $ Pf0gt1iW Fw w mg Wflpound lh above londi9 and pillgt$ ol correc ot are chdoSble 14 day hgt hgt9
1-e dale lh e dnttrenb are lldll avulllle tcent tl1$ hlQIIy I deiOiltmC$ are lied an appro ed pa ol WJeeJO $ bulle iJmiddot$ te 10 o IJlaquo prosrgttm
gta1ocopgtUo
73012010
CAUORNIA HFAl TH AND HUMAN SERVICFS AGENCY
DEPARTMENT OF PUBLIC HEAlTH
$ 1TEMfNT JFDEIIt MgtlS XT) PROIiDERISlJPPIIERCL( x Mlltll e CONSRCON pgt) DATE 5UflgtEV
AltD PlAN CF COlllOCgtQgti iOfl lrCATiOt NJIltBFR COoPlffFD A 3JL0iNG
050100 3 WigtC 062912010
N-YF CW OvllER OR SJFPUI STRC - AI)JRESS CrY GT TE l P CODE John Muir Meikll CantO Imiddot Walnut CrQek 1f(l1 YGNACIO V4LLEY ROAD WAlNUT CREEK CA 94598 CONTRA COSTA
CarnpU$ COUNTY
X4)10 PiiEFI
TAG
S t1MARY OnYMIENTO OCFICifN(IES (Efo(li O FCiENbullV IJ$7 IE PRtCEEDED W FL
lfCVATOltr OR lScent llflIFYImiddotKgt NIOilMAlQo
Continued From page 4
Reasolable precaJtb s must be a- en to
rrniMire the chance of inadvertent disdosure of PHI to d1viduals wo tio not have a Jeed lo know middot
iREF X
TAC
PIltOVOERS PLAl OF CCR EC710N
I ACH COR ECtfCACT ON StiOIIU a CROSS-
Rgt(RfNCEO fO THpound 1PPROJgtCIAft OE VfNCY)
15) COJ ETE
Dl1
i
i
I
i
I I
i
Event IDYR3L 11 9 044AM
LAB RATOOY DIRECTORS OR fROvltlERSUfPUER REPRESENTATlVES SIGNAlURE TITLE Zfi) CPTE
Agty dllltcim1q stafemliN(IdiJIg wrh ao ijSem 1bull1 ltlltllfnl a dehrllmcy hdgt hlt in iluten may l8 excu ed I row ccnectm1 proHdlng n m riebummed lhlll o er ampafegusnhi piClt tie gtcJffi ienl prolecboo In te pabllnt_ E=eplorron Jg homgt hefnltfrg above am ltil ble 00 CBJ fuowiCoQ It ltlaW Q trtiJ1 whetter Of IQ a piJin JI orrectlim is wov for nuraing ht11$ 1e lilllole lindlfl91 ltgtd plans o corroctiOf alo lisdosable H aay JulQWill tie dalE lhew docurombullgt are rrade ampva1labW ttl he lacility 1 1ooendes ruq Cliae an tpprQffld p-all ot CllllKl Pn tamp requisill W WIMJCltl progr
ooerocpallttlll
lt21 MUL Tl~LE COfSt~uCTiOt
NAME CF PROVIDER Cll SUPPl iEll
--middotmiddotmiddot-------------------------------------------------------------------
CALIFORNIA HEALIH AND HUMAN SERVgtCES AGWCY DEPARTMENT OF PJKIC HEAc rH
S1ATEME1T Dt DEFICIENIf$ (X1l PPcentVDEltSc-PPlEltiClA ( 11 JAT[ SvRVCt iD PIAN OF COltRltTION bullOamphTIbullmiddotCA middotON NWJBER COMLTED
A BUILDING
0501811 B W1NG 1292010
STREET ADORtSS CITY STATE I COD
John Muir Medital CM1er- Walnut Crook 1601 YGNACIO VALLEY ROAD WALNUT CREEK CA 94593 CONTRA COSTA
Campus COUNTY
M IJ SUMIIAIY SlATEAtJH OF lEfiIEIJCfS (l CH OEfiCilNCY MUST bpound FfltrCrrDO flr ltl l RFGcJLATORY OR lSC 0E TIYmiddotNGgt IH MATIOIIJ
Ff10VII)[ S PLAN 7 CCRRECTON f(5) PRU-IX f-C-i COlHftTIIf AOION SHOUlD BE CROSSmiddot COIWLPE
REFEREiCfO TO Hlf AFPROPRIltTf OHICLNC1) OATE
Continued From paglt l
lhe aief1ls rectYd A ccorJmiddotg to he rctdenl i Repcli the ETiergelcy Deparllllerl Patient
nknnallon Shffitl CChid sil in he amp-et for vp lo two days An ED 1ead clerk and a ED t1ansporter
i (staff assigned the duties of transporting patients
withm the hosp ital) W1Ht kwesligaled by the hOspital and found to be relatelt to lgte person
respoiSbe for lle identity heft The mc1dent was
still uider iWestgabon by a police task force
Observation en 6130110 at 10lt30 am_ of he Emergency Departrret the OeSeuroCeuro of ED
Manage showed hree areu ca ed pods tat
Were desk area s wth a glass wall fl 111e front of the
desk Entry to 11e cd area was by way of ar1 open
walkway at e11ner eoo cf the desk Ttere was no
I door cr Pa1ilicn Pod 3 had a desk facing the glass
wall had ccrrpuler termin als and chairs flttCif19 the g la ss wa1 and a co vnter behind the de$1lt with a
basket holding completed admitf1ng papers en It
The EO Manager stated the lead cerk wor ked at
Pod 3
The hospital POlicy tbulltko PHImiddot Pnvacy PrlttciCfls
Uses and DlsclosiES of Proleded 1-ealth
lnformalcn revsed 9G7 aXl lteveWed on 5120110 slated workforce rrem rs (eTiployee vclunteers
ctlleS )lysicans and ohar alliiXl health
professionals whle I)CVdti9 cae may net UStgt or
disclose PHI in a manner bullncotlssten wilh federal
and slate Jaw$ aod regulatons The policy
inslrucieltl staff 10 make sure ttlat medical
middotinformation tat identifies he p atient is ltepl private
i e-cept as the palienl authcnzes or as laws requhlt
IX oermit The p licy further inslvcted
i i
j o
Event iDYRjl11 730200 91044AM
IlTLE (XgtI OATE
Any ooticgtenoy $llemtml ntlmiJ w1gt an a llrw n wnola 11 trlt-middot011Cf whch rte on$ 1 1ion may be excused rom cmrRMg prtWitllt1 middott middot tleettYIIcent tNH omr sttQlt111amp ptevtle $All litgt I gtrJcentCho w h cuen5 Ebullcem lorlvrsig hon1e the 11ndogs abOve Mgt dbull lltgt5 bkl C days llogt9 he daHl
af yen hihl m net a pan Ol ltXWltteJO $ Pf0gt1iW Fw w mg Wflpound lh above londi9 and pillgt$ ol correc ot are chdoSble 14 day hgt hgt9
1-e dale lh e dnttrenb are lldll avulllle tcent tl1$ hlQIIy I deiOiltmC$ are lied an appro ed pa ol WJeeJO $ bulle iJmiddot$ te 10 o IJlaquo prosrgttm
gta1ocopgtUo
73012010
CAUORNIA HFAl TH AND HUMAN SERVICFS AGENCY
DEPARTMENT OF PUBLIC HEAlTH
$ 1TEMfNT JFDEIIt MgtlS XT) PROIiDERISlJPPIIERCL( x Mlltll e CONSRCON pgt) DATE 5UflgtEV
AltD PlAN CF COlllOCgtQgti iOfl lrCATiOt NJIltBFR COoPlffFD A 3JL0iNG
050100 3 WigtC 062912010
N-YF CW OvllER OR SJFPUI STRC - AI)JRESS CrY GT TE l P CODE John Muir Meikll CantO Imiddot Walnut CrQek 1f(l1 YGNACIO V4LLEY ROAD WAlNUT CREEK CA 94598 CONTRA COSTA
CarnpU$ COUNTY
X4)10 PiiEFI
TAG
S t1MARY OnYMIENTO OCFICifN(IES (Efo(li O FCiENbullV IJ$7 IE PRtCEEDED W FL
lfCVATOltr OR lScent llflIFYImiddotKgt NIOilMAlQo
Continued From page 4
Reasolable precaJtb s must be a- en to
rrniMire the chance of inadvertent disdosure of PHI to d1viduals wo tio not have a Jeed lo know middot
iREF X
TAC
PIltOVOERS PLAl OF CCR EC710N
I ACH COR ECtfCACT ON StiOIIU a CROSS-
Rgt(RfNCEO fO THpound 1PPROJgtCIAft OE VfNCY)
15) COJ ETE
Dl1
i
i
I
i
I I
i
Event IDYR3L 11 9 044AM
LAB RATOOY DIRECTORS OR fROvltlERSUfPUER REPRESENTATlVES SIGNAlURE TITLE Zfi) CPTE
Agty dllltcim1q stafemliN(IdiJIg wrh ao ijSem 1bull1 ltlltllfnl a dehrllmcy hdgt hlt in iluten may l8 excu ed I row ccnectm1 proHdlng n m riebummed lhlll o er ampafegusnhi piClt tie gtcJffi ienl prolecboo In te pabllnt_ E=eplorron Jg homgt hefnltfrg above am ltil ble 00 CBJ fuowiCoQ It ltlaW Q trtiJ1 whetter Of IQ a piJin JI orrectlim is wov for nuraing ht11$ 1e lilllole lindlfl91 ltgtd plans o corroctiOf alo lisdosable H aay JulQWill tie dalE lhew docurombullgt are rrade ampva1labW ttl he lacility 1 1ooendes ruq Cliae an tpprQffld p-all ot CllllKl Pn tamp requisill W WIMJCltl progr
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73012010
CAUORNIA HFAl TH AND HUMAN SERVICFS AGENCY
DEPARTMENT OF PUBLIC HEAlTH
$ 1TEMfNT JFDEIIt MgtlS XT) PROIiDERISlJPPIIERCL( x Mlltll e CONSRCON pgt) DATE 5UflgtEV
AltD PlAN CF COlllOCgtQgti iOfl lrCATiOt NJIltBFR COoPlffFD A 3JL0iNG
050100 3 WigtC 062912010
N-YF CW OvllER OR SJFPUI STRC - AI)JRESS CrY GT TE l P CODE John Muir Meikll CantO Imiddot Walnut CrQek 1f(l1 YGNACIO V4LLEY ROAD WAlNUT CREEK CA 94598 CONTRA COSTA
CarnpU$ COUNTY
X4)10 PiiEFI
TAG
S t1MARY OnYMIENTO OCFICifN(IES (Efo(li O FCiENbullV IJ$7 IE PRtCEEDED W FL
lfCVATOltr OR lScent llflIFYImiddotKgt NIOilMAlQo
Continued From page 4
Reasolable precaJtb s must be a- en to
rrniMire the chance of inadvertent disdosure of PHI to d1viduals wo tio not have a Jeed lo know middot
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Event IDYR3L 11 9 044AM
LAB RATOOY DIRECTORS OR fROvltlERSUfPUER REPRESENTATlVES SIGNAlURE TITLE Zfi) CPTE
Agty dllltcim1q stafemliN(IdiJIg wrh ao ijSem 1bull1 ltlltllfnl a dehrllmcy hdgt hlt in iluten may l8 excu ed I row ccnectm1 proHdlng n m riebummed lhlll o er ampafegusnhi piClt tie gtcJffi ienl prolecboo In te pabllnt_ E=eplorron Jg homgt hefnltfrg above am ltil ble 00 CBJ fuowiCoQ It ltlaW Q trtiJ1 whetter Of IQ a piJin JI orrectlim is wov for nuraing ht11$ 1e lilllole lindlfl91 ltgtd plans o corroctiOf alo lisdosable H aay JulQWill tie dalE lhew docurombullgt are rrade ampva1labW ttl he lacility 1 1ooendes ruq Cliae an tpprQffld p-all ot CllllKl Pn tamp requisill W WIMJCltl progr
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