Medical papers found in trash bin may lead to fines

June 7, 2007

By Ken Borsuk, Staff Reporter

A box left in a trash bin could end up leaving some local doctors a little lighter in the wallet.

The Greenwich Post was given a box filled medical documents from the Dearfield Medical Building that may have been improperly disposed of. The box was discovered at 4 Dearfield Drive inside a trash bin in May and contains information about lab tests and insurance approvals as well as other medical issues. These documents are not medical charts, but do contain patient names and contact information.

According the United States Department of Health and Human Services, under the privacy regulations for the Health Insurance Portability and Accountability Act (HIPAA), documents such as the ones in the trash bin are supposed to be kept confidential and then shredded when disposed of, not just thrown out in a box.

While it was not confirmed from which office at the medical building all the documents originated, the names of Alfred Padilla and Judith Goldberg-Berman, who run an endocrinology practice in the building, appear frequently on the documents.

Dr. Padilla spoke to Greenwich Post on Tuesday and expressed surprise that the documents had not been shredded. He said it was the practice's policy to make sure all medical documents were properly disposed of.

"We take HIPAA very seriously," Dr. Padilla said. "In general we will shred everything we throw away."

Dr. Padilla said there were some documents that were kept in a room at the practice to be shredded, but hadn.t yet been. He speculated that the cleaning crew at the building might have accidentally disposed of them.

"We have a pile of boxes to be shredded," Dr. Padilla said. "If the cleaning people came and took the box, mistaking it for garbage, that would have been what happened... My suspicion is that one of our shredding boxes ended up in the trash bin. That's the only theory I can come up with."

Dr. Padilla added he would not notice if one of the boxes went missing because he would assume it had been shredded.

Dr. Goldberg-Berman said she was sorry about anyone.s records ending up in the trash and stressed she had no idea how it happened because the practice shreds its records regularly to dispose of them.

The cleaning crew was hired by and report to Alan Management, which manages the building. Greg Helms, president of the company, said the individual tenants set aside what is to be thrown out in the Trash bin and the cleaning crew doesn.t make distinctions between what is proper to throw out and what isn.t. It just removes what is left out for it.

"It sounds like a lot of finger pointing to me," Mr. Helms said on Tuesday. "The cleaning crew is throwing away what they believe the doctors want them to throw away. They don.t go hunting for items to be thrown out. It's possible that this is what happened here, but you shouldn.t be passing blame to the cleaning crew."

Mr. Helms said he would speak to the cleaning crew to make sure they got in contact with the doctors at the building to make sure there was a clear understanding about what was supposed to be thrown out and what was to be left there. Mr. Helms said it was possible this was all "an innocent mistake" and he wanted to make sure both the doctors and the cleaning crew knew what had to be done.

Dr. Padilla said there was usually no problem with the cleaning crew but .I could see how they could make a mistake..

If the records are found to have been improperly disposed of, the practice could face charges for damages. Susan McAndrew, deputy director for health information privacy at the federal Office of Civil Rights, said that if an investigation determined the records had been improperly disposed of and action had not been taken to correct the problem to the satisfaction of the Secretary of Health and Human Services, then those responsible could face a fine of up to $100 per violation. Since there was a box of documents, the number of potential violations cannot yet be determined. Under civil monetary penalties, this would not exceed $25,000 per calendar year for each identical requirement or prohibition that has been violated.

Ms. McAndrew said there would have to be an investigation in order to determine if there had been any wrongdoing. One has not yet begun and won.t unless the department receives a complaint. Only after a complaint is filed can an investigation begin.

Most health plans and health care providers are covered under HIPAA.

"The only information we don.t protect is information where steps have been taken to identify whose information it is," Ms. McAndrew said. "If the name of the person is deleted or obscured, then it's not covered. We cover information that gives away the person.s name, Social Security number and address."

While Ms. McAndrew could not discuss specifics or say for certain whether the documents were covered under HIPAA without examining them herself, the documents did appear to fall under the rule.

"A record that identifies the patient as having received services from a facility - it would, in general, be the type of information that the rule would protect," Ms. McAndrew said.

Greenwich Post was first told about the documents on May 24 after receiving a phone call from a source who discovered the box while working. The source contacted the Post because of concerns about the records not being disposed of properly and patients. privacy being violated.

In addition to the records, the box contained several magazines though there were no address tags to indicate which office had the magazines.

"There are safeguards in place when it comes to disposing of paper records," Ms. McAndrew said. "Shredding is an acceptable safeguard, but just dropping them in the trash is not."

The Post plans to hold the box for a period of time. If no complaint is filed it will be returned to the medical group for proper disposal.

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