Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530015 (X3) Date Survey Completed 07/13/2017
Name of Provider or Supplier St Johns Medical Center Street Address, City, State 625 East Broadway, Jackson, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0441 PROTECTING PATIENT RECORDS
CFR(s): 482.24(b)(3)

The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas.


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to protect medical record information from unauthorized use in 2 of 3 locations (outdoor storage, basement storage) where medical records were stored. The findings were: 1. Observation on 7/11/17 at 1:30 PM with HIM staff #1 in the facility basement showed medical records stored along metal shelving at 5 rows up at 10 feet high, and 6 separate sets of shelving 30 feet long. The shelving space was full with the records. HIM staff #1 confirmed at that time that the maintenance staff have a key to access the stored medical records. 2. Observation on 7/11/17 at 1:45 PM with HIM staff #1 in a storage building outside of the facility (on the facility grounds) showed medical records stored on shelving 10 feet up and 30 feet long. The shelving space was full with the records. At that time maintenance staff #1 had to unlock the storage building for access, and at that time HIM #1 confirmed that the maintenance staff have key access to the stored medical records. 3. Interview with the maintenance director on 7/12/17 at 12:40 PM confirmed the maintenance staff had key access to the stored medical records, and did not have a need to know the information contained in those records.