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CLARKS SUMMIT STATE HOSPITAL
ORGANIZATION OF REHABILITATION SERVICES
Tag No.: A1124
Based on review of the Governing Body Bylaws, physical therapy policy manual, and interview with the facility staff (EMP), it was determined the facility failed to ensure there was a current manual defining the services provided by the department.
Findings include:
Review of the facility's Bylaws of the Governing Body, dated last reviewed August 2008, revealed "Article I Hospital policies are reviewed and/or revised on an ongoing basis but at least every three (3) years depending on the function.
Review of the physical therapy department policy manual revealed there had not been a review of the policies since 1998.
Interview with EMP1 on January 6, 2011, at approximately 1:30 PM confirmed that the policy and procedure manual for the department was not current and had not been reviewed every three years.