INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 7, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Aldie Counseling Center was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
During the physical plant inspection discharged client files were observed in boxes on shelves and scattered in other boxes around the garage. Although the area was locked there were other items being stored in the garage, such as paint cans and maintenance supplies for the facility, which would indicate non clinical employees have access to these records. This information was shared with the facility staff in order to address the condition.
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Plan of Correction
The discharged client files have been relocated to a secure location. The secure location contains only discharged client records. No other materials or supplies are stored in this area. In addition, the Operations Manager has met with the administrative support staff and the file clerk and has clarified that no client information is to be stored in the garage area where the other supplies are located. The Operations Manager will ensure compliance by inspecting the subject area not less than twice monthly. |