Observations
Based on documentation of feedback from former clients, comments by clients presently in treatment, and a physical plant inspection, the facility failed to provide beds with mattresses which were in good repair for each client.
The findings included:
A physical plant inspection was conducted on May 20, 2009 during an unannounced onsite complaint investigation and samples of mattresses in each room were inspected. Cracked and/or torn mattresses were observed in client rooms # 2, 5, 6, 7, 8, and 9. A total of fourteen bedrooms were inspected. Documentation reviewed included client questionnaire forms which clients complete after their course of treatment had been completed. A comment by one client on a questionnaire dated 5/5/09 stated that the "beds and pillows need replacing".
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Plan of Correction
The Director of Opertions and Maintenance Manager inspected all matresses on 6/8/09. Twelve matresses were identified in need of immediate replacement. Twelve new matresses were ordered on 6/11/09. In addition, twelve new pillows were ordered. Prior to this inspection, we had been in the process of replacing matresses and had already replaced 15. The Maintnenace Manager under the direction of the Director of Operations will inspect the remaining old matresses on a monthly basis. He will report any new needs to the Director of Operations. Colonial House will continue to replace matresses and pillows as necessary until all have been replaced. |