Complaint Investigation Report

On the allegation – Staff did not safeguard clients’ confidential information

It was alleged that staff talk about people’s private information in the open main office or with the medication room doors open, so clients can hear confidential conversations.

This is the third complaint received regarding the safeguarding of client confidentiality at this facility.

Facility tours were conducted on 4/15/25, 4/17/25, and 7/31/25. During these visits, LPA observed that the main support staff office, referred to as the “hub,” contained a whiteboard displaying client initials, room numbers, and diagnoses. This board was located on the right wall and was visible from the doorway. Photographs of the board were taken on 4/15/25 and 7/31/25. The whiteboard was not covered and could be easily seen during interactions between staff and clients at the hub door. As of 10/31/25 the whiteboard has been removed and is now closable and not visible by the doorway.

Staff interviews confirmed that maintaining confidentiality is challenging due to the hub’s central location and frequent client interactions at the doorway. While staff did not report intentionally discussing confidential information in open areas, they acknowledged the difficulty in preventing conversations from being overheard.

Interviews with prior management who have now since moved on and a review of internal “Manager Note” further confirmed that there have been instances where staff left Protected Health Information (PHI) documents visible when stepping away from the hub. Additionally, it was noted that PHI has been left visible on desks when clients approach the hub door to speak with staff, increasing the risk of unintentional disclosure.

Previous complaints received on 4/10/25 and 4/16/25 raised similar concerns about visible client information and conversations occurring in areas where others could overhear.

Based on LPA’s observations, staff and management interviews, documentation review, and the recurrence of similar complaints, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (see LIC 9099-D).