INITIAL COMMENTS
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This report is a result of a review of an unusual incident report conducted on July 29, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the review, Gaudenzia Focus House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on the review of two unusual incident reports submitted to the Department, the facility failed to keep client identities confidential.The unusual incident report submitted on 7/22/22 identified the client using their first and last name.The unusual incident report submitted on 7/27/22 identified the client using their first and last name.
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Plan of Correction
MH Division Director will complete DDAP Incident Report in-service training with entire Focus House Staff on August 17, 2022 at mandatory monthly staff meeting.
All DDAP incident reports will identify (resident) utilizing AVART ID #.
Program Supervisor will review all DDAP incident reports prior to submission to ensure compliance with all DDAP requirements. |