Observations
Based on the review of client records, the facility failed to document a physical examination in two of ten client records.
The findings include:
Ten client records were reviewed on December 18-19, 2013. Ten client records required documentation of a physical examination. The facility failed to document a physical examination in client records # 4 and 8.
Client # 4 was admitted on July 11, 2013. The facility failed to document that a physical examination had been completed for client # 4 as of December 19, 2013.
Client # 8 admitted on April 22, 2013. The facility failed to document that a physical examination had been completed for client # 8 as of December 19, 2013.
The Facility Director, Clinical Supervisor and Therapist were interviewed on December 19, 2013 and confirmed the findings.
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Plan of Correction
POWER's Halfway House will maintain documentation of a physical examinantion in the client records.
The Program Manager will provide oversight and routinely review client records to ensure there is a documented physical examination. The Program Manager will educate referral sources and physcial health care providers that routinely provide physical exams of Halfway House clients of what needs to be documented in regards to the physical examinations. The Program Manager will ensure clients that need a physcial exam are scheduled within 7 days of admission. POWER's Halway House will be in full compliance by 1/27/14. |