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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.

Findings included:

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 patients' individually identifiable health information and that the method was effective and in compliance with hospital policies .

Findings included:

Refer to TAG A-0267, # A-0441

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.

Findings include:

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 contractual agreement between the Hospital and the Pathology Service was reviewed. The agreement stated the corporation (group of physician), and (its) Physician, shall be directly responsible to the Hospital's Medical Director and to the Hospital's Vice President of Operations for operational matters. At all times the Corporation (group of physicians) shall ensure that the physicians rendering services.......................................(3) abide by all applicable bylaws, rules, regulations and policies of the Hospital.

The Hospital policy that addressed disposal of confidential documents was reviewed. The Policy stated it is the policy of the hospital to dispose of documents which contain confidential information in such a way that individuals and the hospital's right to privacy is protected. Documents which contain patient or other confidential information, when being disposed of, must be shredded or disposed in a secure container designated for shredding. Protected information is any data or information which identifies an individual patient, physician or employee and included but is not limited to the following: name, address, employer, relatives names, date of birth, phone or fax number, e-mail address, social security number, medical record or account number, policy number.

The Vice President of QI and Risk Management, was interviewed in person on 8/17/10 at 9:25 AM. The Vice President of QI and Risk Mangement said he/she had contacted the the owner of the billing company that the pathology service use and discovered the owner had retired in the early summer of 2010. The VP of QI and Risk Management said the owner had related that there were approximately 2 to 3 years worth of record that he/she had on hand at the time of retirement and the records had been given to a family member for disposal. The family member had assured the former owner the records had been burned. The Vice President of QI and Risk Management said the pathologist understood their obligation regarding the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and all physician have signed statements that they will abide by all Hospital policies, therefore how the protect health information was being dispose of by the contracted pathology service group was not monitored by the Hospital. The VP of Quality Improvement and Risk Management said he/she did not know if there was specific language in the contract agreement between the previous billing service or the current billing service and pathology service group, related to the appropriate manner to dispose of protect health information, because the pathology group were unable to find their contract agreement with the billing company.


Also refer to A-0083, A-0084, A-0267, A-0442

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