INITIAL COMMENTS
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This report is a result of a review of an unusual incident report conducted on August 1, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the review, Gateway Rehabilitation Center 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 a review of an unusual incident report submitted to the Department on July 28, 2022, the facility failed to keep the client's identity confidential. This report contained the client's first and last name.
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Plan of Correction
1. The Regional Director of HIM & Compliance reviewed and updated the Confidentiality Policy and Procedure.
2. All applicable staff shall receive a copy of the updated Confidentiality Policy and Procedure via Email.
3. All applicable staff responsible for submitting Reportable Incidents shall be educated on the updated Policy and Procedure.
4. The Director of HIM shall audit all Reportable Incident Reports to ensure they do not contain Protected Health Information (PHI).
5. Completion Date 8/30/22
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