Observations
Based on a review of what was submitted by the complainant on January 25, 2026, the facility failed to ensure clients confidentiality.The logbook in the complainant ' s possession had the following identifying information: client name, age, birth date, sex, admit date, patient ID number and MR number.The date of the breach ranged from 10/15/2020 through 9/30/2023.Facility notified of this breach on 1/26/2024.
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Plan of Correction
On 1/26/24 CEO reported confidentiality breech to Acadia legal and corporate compliance team for incident reporting and additional data breech reporting. On 1/28/24 CEO retrieved the composition notebook from the patient. On 1/29/24 risk team conducted investigation on how the confidentiality breech occurred, it was determined that the notebook was inadvertently mistaken for the patients belongings and placed in the patients confiscated items.
The composition book containing patient information has been taken out of circulation due to common appearance and archived. Risk manager has created a bright, labeled 3-ring binder where staff can record contraband findings. Rather than using patient identifying information, this process will now use facility medical record number and admission date to identify and record confiscated contraband. All intake and safety search staff will be trained on the use and process of this new contraband binder, with emphasis on importance of confidentiality in recording data in the binder. Training will occur by 2/5/24. Intake and safety search supervisor will monitor use of and location of the contraband binder weekly.
Legal counsel is also looking at the HIPAA reporting regulations and planning for us to send a confidentiality breech letter to the patients impacted by this event. The total patients impacted by the breech equaled 139. The letters will be completed and sent by 2/9/24.
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