DEPARTMENT OF HEALTH 8: HLMAN SERVICES OFFICE OF THE SECRETARY Voice - {tom (soot 3 all'?ti Of?ce for Civil Rights, Region "Inc TDD 2201 Sixth Avenue, Mail Stop RK-ll (FAX) - (20(1) 615-329? Seattle. lmill-1331 u. w. hhs. aovi?ocrf Date: APR 15 2011 {bll?iiblliilcl {bll?libllilicl Director VA Puget Sound Healthcare System 1660 S. Columbian Way Seattle, WA 98018 RE: Transaction number 11-12-4930 Deal. and On March 11, 2011, the US. Department of Health and Human Services (HHS), Of?ce for Civil Rihts OCR) received a complaint ?'om (Complainant) on behalf of her ex-husband lleging a violation of the era an ards for Privacy of Individually Identi?able Health Information andfor the Security Standards for the Protection of Electronic Protected Health Information (45 CPR. Parts 160 and 164, Subparts A, C, and E, the Privacy and Securit Rules). Speci?cally, Complainant alleged that on the night of March 4, 201 1, she accompanied to the emer encv room the Seattle Division of the VA Puget Sound Healthcare System She alleged that was having a medical emergency in that several inches of his intestines were leaking into his colos1:om ba . When they arrived at the facility, Complainant alleged that from staff did not attend to a timely manner nor did they treat his situation as an emergency even thou was vomiting from pain and more ofhis intestines were leaking into his colostomy bag. At one point, Complainant requested staff to $ka colostomy bag due to their concerns that the bag may explode. In res nse a staff mem er came out into the waiting room where as waiting, requested 0 lift his shirt, examined him, stated that the bag was not in danger of exploding, and left. When Comlainant attempted to oomplain to a patient advocate about quality of care issues surroundinreatment, she was directed to the facility?s privacy of?cer. This allegation re?ected a possible violation of 45 CPR. 164.530(c) (safeguards). OCR enforces the Privacy and Security Rules, and also enforces Federal civil rights laws which prohibit discrimination in the delivery of health and human services because of race, color, national origin, disability, age, and under certain circumstances, sex and religion. Under the Privacy Rule, covered entities must adopt administrative, technical, and physical safeguards to limit incidental disclosures and avoid prohibited uses and disclosures. See 45 C.F.R The Privacy Rule does not require that all risk of incidental use or disclosure be Letter to I Page 2 01?2 Transaction 1-124980 eliminated to satisfy its standards. Rather, the Rule requires only that covered entities implement reasonable safeguards to limit incidental uses or disclosures. See 45 C.F.R. On March 30, 2011, OCR provided notice to VA Puget Souud Healthcare System of this complaint by telephone through their privacy of?cer, OCR provided background on the case and gave technical assistance on the safeguards provisions 0! the Privacy Rule. She indicated that she was not familiar with Complainant?s allegations but agreed that there could have been additional safeguards taken in this case. She indicated that she would pass forward the technical assistance provided by OCR to her director. As for the quality of care issues presented by Complainant, it is unclear whether Complainant was provided an adequate avenue at the VA Puget Sound Healthcare System to complain about this matter or whether her concerns were addressed. To assist Complainant, OCR referred her to the Jo int Commission at 1?800-994-6610 as the VA Puget Sound Healthcare System Seattle Division is accredited by that organization. Based on the technical assistance provided by OCR, no further OCR action is required at this time. Therefore, OCR is closing this case determination as stated in this letter applies only to the allegations in this complaint that were reviewed by OCR. Under the Freedom of [nformat ion Act, we may be required to release this letter and other information about this case upon request by the public. In the event OCR receives such a request, we will make every effort, as permitted by law, to protect information that identi?es individuals or that, if released, could constitute a clearly unwarranted hivasion of personal privacy. If you have any questions regarding this matter, please contact Sarah Brown, Investigator, at 206- 615-2293 (Voice), (206) 615-2296 (TDD). Sincerely, Connor Linda Yuu Connor Regional Manager