INITIAL COMMENTS
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This report is a result of client information that was faxed to the Department's unusual incident fax line on October 9, 2019 by Mid- Atlantic Rehabilitation Services. Staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division investigated the fax content and Mid- Atlantic Rehabilitation Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this investigation and a plan of correction is required.
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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 faxed documents on October 9, 2019 via fax, the facility failed to ensure that the client's identity was secured.
The Department received client identifying information via fax that was supposed to be faxed to a provider by mistake.
These findings were reviewed with facility Director.
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Plan of Correction
All MARS staff will be required to review the DDAP approved confidentiality policy in place at MARS by 11/10/2019 and sign a document acknowledging their review and understanding of the approved confidentiality policy and procedures. MARS Project Director will ensure distribution of this policy and document identifying review and understanding of policy. |