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Based on interview and documentation review it was determined the Hospital failed to ensure the contracted pathology service was in compliance with all of the Conditions of Participation and that patients' individually identifiable health information was disposed of appropriately to protect their privacy, in accordance with standards of practice.

Refer to TAG # A-0441

Based on interview and documentation review it was determined the hospital failed to ensure the Quality Assurance activities conducted in relation to the contracted pathology service included evaluation of the method utilized for disposal of of patients' individually identifiable health information and that the method was effective and in compliance with hospital policies .

Refer to TAG # A-0441, A-0267

Based on interview and documentation review it was determined the hospital failed to measure and track how patients' individually identifiable health information was disposed of by the contracted pathology service to ensure all patients' personal privacy was maintained.

Refer to TAG # A-0441

Based on interview and documentation review it was determined the Hospital failed to ensure the confidentiality of all patients medical record information was maintained by the contracted pathology service in accordance with hospital policies.

Findings included:

The agreement between the Hospital and the Pathologist was reviewed. The agreement stated the Doctor agrees to provide such services to the best of his/her ability and to abide by the regulations and policies of the Hospital.

The business associate agreement between the Pathology Associates and the billing company, dated April 10, 2003 was reviewed. The Agreement stated in order to comply with the health insurance portability and accountability act of 1996 and implementing regulations the billing company agree as follows:..................................#13 Upon termination of its relationship with the Pathology Associates the billing company shall, if feasible return and destroy all of the protected health information that the billing company still maintains in any form and shall retain no copies of such information. If such return or destruction is not feasible, the billing company shall extend the protection of this agreement to the protected health information and shall limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible.

The Contracted billing service had failed to follow the business associate agreement as evidenced by its inappropriate disposal of documents containing personal health care information and personal identification information at a trash transfer station.

The Hospital policy that addressed disposal of records containing personal information was reviewed. The policy stated paper documents containing Personal Information must be redacted, burned, pulverized or shredded so that Personal Information cannot practicably be read or reconstructed.

During the 8/17/10 Survey the President of the Hospital, the Chief Financial Officer and the Privacy Officer/Director of Medical records were interviewed at various times and requests were made to review the quality assurance monitoring data of the Pathology group's handling/disposal of records containing personal information provided by the Hospital to the pathology group for billing purposes. The Privacy Officer said the QA performed for the contracted pathology group did not included their handling/destruction of documents containing person information.

Based on interview and documentation review it was determined the Hospital failed to ensure there was an adequated and established system in place to ensure unauthorized individuals could not access the records of patient provided services by the hospital contracted pathology service.

Findings included:

Refer to Tag A-0441

Based on interview and documentation review it was determined the Hospital failed to ensure the contracted pathology service was in compliance with all of the Conditions of Participation and that patients' individually identifiable health information was disposed of appropriately to protect their privacy, in accordance with standards of practice.

Refer to TAG # A-0441

Based on interview and documentation review it was determined the hospital failed to ensure the Quality Assurance activities conducted in relation to the contracted pathology service included evaluation of the method utilized for disposal of of patients' individually identifiable health information and that the method was effective and in compliance with hospital policies .

Refer to TAG # A-0441, A-0267

Based on interview and documentation review it was determined the hospital failed to measure and track how patients' individually identifiable health information was disposed of by the contracted pathology service to ensure all patients' personal privacy was maintained.

Refer to TAG # A-0441

Based on interview and documentation review it was determined the Hospital failed to ensure the confidentiality of all patients medical record information was maintained by the contracted pathology service in accordance with hospital policies.

Findings included:

The agreement between the Hospital and the Pathologist was reviewed. The agreement stated the Doctor agrees to provide such services to the best of his/her ability and to abide by the regulations and policies of the Hospital.

The business associate agreement between the Pathology Associates and the billing company, dated April 10, 2003 was reviewed. The Agreement stated in order to comply with the health insurance portability and accountability act of 1996 and implementing regulations the billing company agree as follows:..................................#13 Upon termination of its relationship with the Pathology Associates the billing company shall, if feasible return and destroy all of the protected health information that the billing company still maintains in any form and shall retain no copies of such information. If such return or destruction is not feasible, the billing company shall extend the protection of this agreement to the protected health information and shall limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible.

The Contracted billing service had failed to follow the business associate agreement as evidenced by its inappropriate disposal of documents containing personal health care information and personal identification information at a trash transfer station.

The Hospital policy that addressed disposal of records containing personal information was reviewed. The policy stated paper documents containing Personal Information must be redacted, burned, pulverized or shredded so that Personal Information cannot practicably be read or reconstructed.

During the 8/17/10 Survey the President of the Hospital, the Chief Financial Officer and the Privacy Officer/Director of Medical records were interviewed at various times and requests were made to review the quality assurance monitoring data of the Pathology group's handling/disposal of records containing personal information provided by the Hospital to the pathology group for billing purposes. The Privacy Officer said the QA performed for the contracted pathology group did not included their handling/destruction of documents containing person information.

Based on interview and documentation review it was determined the Hospital failed to ensure there was an adequated and established system in place to ensure unauthorized individuals could not access the records of patient provided services by the hospital contracted pathology service.

Findings included:

Refer to Tag A-0441