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 530025 (X3) Date Survey Completed 11/03/2011
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, 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)
A0442 SECURITY OF MEDICAL RECORDS
CFR(s): 482.24(b)(3)

[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.


This STANDARD is not met as evidenced by:
Based on observation, staff interview and review of policies and procedures, the facility failed to safeguard the confidentiality of health information by restricting access to medical records to only those employees involved in patient care, quality assessment and utilization review, and health information management. The findings were: Observation on 11/1/11 at 2 PM and again on 11/3/11 at 10 AM revealed a large storage room on the first floor east. Entry into the room was available from two locations: from the medical records department and from a corridor door located on the other side of the large storage room. In addition, the large storage room was separated into two areas: a small caged area and a much larger storage area. The caged areas were accessible from the medical records department, and access to the larger area was directly through the corridor door. Only medical records were stored in the small caged area; however, at least 50 boxes containing paper copies of closed medical records, as well as other supplies and radiology materials, were stored in the larger area. A locked door in the cage separated the two areas. Interview with the health information manager on 11/1/11 at 2 PM revealed the door from the corridor was always locked and access could only be gained by using a master key. Further interview and review of the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, revealed several departments had access to the medical records storage area including medical records, radiology, nursing, administration, security and maintenance. Each of these departments had a "master key" for access into the large storage area. Depending upon circumstances, the time of day, work schedule, etc., a department's master key was available to more than one employee of that department during and after business hours. However, according to the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, access after hours in emergencies was limited to administration, nursing and engineering employees.