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F0583
E

Failure to Protect Resident PHI During Meal Ticket Disposal

West Hills, California Survey Completed on 08-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect the confidentiality of residents' personal and medical information by not ensuring that documents containing protected health information (PHI) were properly shredded before disposal. During an observation of the dishwashing process, a dietary aide was seen discarding residents' meal tickets, which included names, room numbers, diet orders, and food allergies, directly into the trash. The dietary supervisor confirmed that this was the standard practice and acknowledged that the meal tickets contained sensitive resident information. The supervisor also stated that these documents should have been placed in a confidential bin for shredding, as disposing of them in regular trash exposed residents' information and violated privacy regulations. Further interviews with the Director of Nursing (DON) revealed that the DON was unaware that kitchen staff were discarding diet tickets in this manner. The DON confirmed that such documents contain PHI and should be disposed of securely, either by shredding or by blocking out identifying information. A review of the facility's policies indicated that all personnel are responsible for protecting PHI and that health information should not be disclosed except as permitted by law. The observed practice of discarding meal tickets in the trash was inconsistent with these policies and resulted in a failure to safeguard residents' confidential information.

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