Observations
Based on a review of client records, the facility failed to document a physical examination within seven days of admission in four of eight client records.
The findings include:
Eight client records were reviewed on April 15-16, 2013. Physical examinations conducted within seven days of admission were required in all eight client records reviewed . The facility failed to complete physical examinations within seven days of admission in client records # 1, 3, 6 and 8.
Client #1 was admitted to inpatient treatment on March 4, 2013. A physical examination was due to be completed by March 11, 2013. The physical examination for client #1 was completed on March 13, 2013.
Client #3 was admitted to inpatient treatment on February 15, 2013. A physical examination was due to be completed by February 22, 2013. The physical examination for client #3 was completed on February 27, 2013.
Client #6 was admitted to inpatient treatment on October 23, 2012. A physical examination was due to be completed by October 30, 2012. The physical examination for client #6 was completed on November 6, 2012.
Client #8 was admitted to inpatient treatment on September 21, 2012. A physical examination was due to be completed by September 28, 2012. The physical examination for client #8 was completed on October 8, 2012.
An interview with the facility director and clinical supervisor took place on April 17, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
1. Residential Coordinator and Medical Coordinator will ensure all Pathway to Recovery students receive their physical within 7 days or obtain a copy of a previous physical that has been completed within the last 6 months.
2. Outside In will submit a request for physicals from Juvenile Detention, Children and Youth Shelters and primary care physician through the family when appropriate.
3. Latrobe Family Practice has given Outside In 3 emergency appointments per week to alleviate the waiting period for all Pathway to Recovery Intakes.
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