INITIAL COMMENTS
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This report is a result of a review of unusual incident reports conducted on July 29, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the review, Treatment Trends Inc. Keenan 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 three Unusual Incident Reports submitted to the Department, the facility failed to keep the identity of clients confidential.
Three unusual incident reports, two submitted on 7/25/22 and one submitted on 7/26/22, contained the first and last names of the clients involved in the incidents.
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Plan of Correction
Expectation to use internally-created Client ID reinforced in staff meetings and reflected in minutes at all licensed facilities. Keenan House Staff Meeting held 8/3/22 (Internal Client ID -comprised of first and last initials; day of birth and last 4 digits of Social Security Number) |