INITIAL COMMENTS
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This report is a result of a review of an unusual incident on 7/29/22 by staff from the Bureau of Program Licensure. Based on the findings of the review, Clear Choices, LLC 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 25, 2022, the facility failed to keep the identity of a client confidential. This report contained the client's first and last name.
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Plan of Correction
Facility Director has resubmitted the incident report using only client number. Facility Director will ensure that no incident reports contain client identifying information in the future. Will review the report prior to submission to ensure that confidentiality is maintained for the clients. Facility Director will maintain reports on-site for review at Licensing Inspections. This is an immediate action. |