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The Source® for Safety Cognitive Retraining for Independent Living
Ages: Adults   Grades: Adults         

This Source is the first evaluation tool AND therapy manual to address patient safety issues from a cognitive framework.  Use it to retrain adults to recognize, reason, and problem solve for safety concerns in the hospital, at home, and in the community.


  • Reason and problem solve to improve safety awareness and the ability to respond to situations safely
  • Increase independence and enjoyment of life
  • Use results from The Source for Safety Evaluation to support discharge planning
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** This is a Cloud E-Book that is accessible from any device with Internet access. .

The Source for Safety Evaluation tool and the therapy content are coordinated so you can efficiently identify areas of concern and intervene.  Safety awareness and independence are addressed in the areas of:

  • Room/Bedroom and Bathroom
  • Wheelchairs and Assistive Devices
  • Swallowing and Diet
  • Medications and Health
  • Floors and Stairs
  • Kitchen and Appliances
  • Home Safety
  • Community–Outside
  • Community–Inside
  • General Precautions

The evaluation subtests and treatment materials are divided into two to three levels of cognitive difficulty.  The evaluation scores and treatment difficulty levels are correlated with the FIM™, ASHA's Functional Communication Measures (FCMs), and Minimum Data Set (MDS) Levels.  

The evaluation is easy to administer, score, and interpret.  The 16-page evaluation form may be reproduced from the book or purchased separately in booklet form as The Source for Safety Evaluation.  Use the evaluation results to: 

  • describe and quantify a patient's cognitive awareness and communication of problem-solving abilities
  • make safe and appropriate discharge decisions
  • set appropriate goals
  • target intervention to meet safety needs

Treatment is provided through questions that stimulate convergent, divergent, and evaluative thinking.  The questions present challenging real-life situations to consider and solve.  Clients respond to safety questions, discuss safety-related situations, and rehearse responses. 

SLPs and other therapists working in any level of medical care (e.g., acute, rehabilitation, long-term) and in any setting (e.g., clinic, home health, private practice) will find content to help identify and resolve their clients' safety concerns.  Copy the activity pages or print them from the FREE CD. 

An efficacy study of The Source for Safety Evaluation and the treatment program as outlined in The Source for Safety Cognitive Retraining for Independent Living was completed on 42 patients and clients.  There was a mean gain of 35% in the specific content areas presented during therapy over a two- to six-week period.  In addition, therapy directed to specific areas of safety awareness and problem solving carried over at a significant level to safety areas not specifically addressed during therapy (Fogle, Reece, & White, 2008). 

Copyright © 2008

176-page book plus a CD of reproducible pages, The Source for Safety Evaluation, therapy activities

According to the American Speech-Language-Hearing Association (ASHA) Guidelines for Speech-Language Pathologists in Rehabilitation of Children and Adults with Cognitive-Communicative Disorders After Brain Injury, Division 40 (Clinical Neuropsychology) of the American Psychological Association (APA), and the Royal College of Speech and Language Therapists' (RCSLT) Clinical Guidelines, the following principles are supported:

Speech-language pathologists' assessments generally center around:

  • A battery of speech, language, and cognitive tests resulting in judgments about areas of strengths and weaknesses.  Treatment considerations and planning are based on the assessment results.  Likewise, measures of gains in treatment may be based on re-evaluation using the same battery of tests.
  • Systematically exploring strategies, task modifications, supports, and intervention procedures that will provide functional improvement and support independent living.

Speech-language pathologists' primary treatment goals are:

  • To improve an individual's performance by eliminating or reducing underlying cognitive impairments through restorative and/or compensatory methods.
  • To achieve functional objectives and participate in chosen, real-world activities that improve performance of specific functional tasks, thereby reducing the disability without necessarily reducing the underlying impairment.

The intended intervention outcome of The Source for Safety Cognitive Retraining for Independent Living therapy manual is for individuals to increase their personal independence and take responsibility for their personal safety as much as possible in the hospital, at home, and in the community.  An efficacy study of 42 patients and clients showed a mean gain of 35% in the specific content areas presented during therapy over a two- to six-week period.  In addition, therapy directed to specific areas of safety awareness and problem solving carried over at a significant level to safety areas not specifically addressed during therapy.


Dr. Paul T. Fogle, Lynda Reece, Jeanine F. White


Paul T. Fogle, Ph.D., CCC-SLP, has been involved with safety concerns for four decades.  He worked for the Los Angeles County Fire Department in their Fire Prevention Program, building fire breaks and using flame throwers for controlled burning.  He worked as an emergency medical technician (EMT) in ambulances for three years in Long Beach, California, with a company that had contracts with the police and fire departments.  In 1969, he served as a combat medic in Vietnam.

Paul earned his B.A. (1970) and M.A. (1971) degrees at California State University, Long Beach, in speech-language pathology.  He trained at Rancho Los Amigos Rehabilitation Center with Dr. Chris Hagen, developer of the Rancho Scales of Cognitive Functioning.  After earning his M.A., he worked for two years in a classroom setting with adolescents with neurological damage (primarily TBIs and CVAs) for Los Angeles County Office of Education.  Paul attended the University of Iowa for his doctoral education and training in speech-language pathology, earning his Ph.D. in 1976.  He received clinical training at the University of Iowa Medical Center and the Veterans Administration Hospital, Iowa City.  He was awarded membership in Sigma Xi, the Scientific Research Society of North America, for his research.

Paul has taught at the university level since 1976, teaching courses in anatomy and physiology, neurology, neurological disorders in adults, dysphagia, gerontology, and counseling skills for speech-language pathologists.  For 20 years, he also taught courses in motor speech disorders, voice disorders, and cleft palate.

Paul has maintained a private practice for over 30 years, working primarily with neurological disorders in adults and children, voice disorders, and stuttering.  During most summers, he works in acute, subacute, or convalescent hospitals treating a variety of patients with communication and swallowing disorders.  He is coauthor of the Ross Information Processing Assessment-Geriatric (RIPA-G) (1996) and the Classic Aphasia Therapy Stimuli (CATS) (2005), and is the principal author of Counseling Skills for Speech-Language Pathologists and Audiologists (2004).  He is the author of Foundations of Communication Sciences and Disorders (2008).

Paul has been involved in forensic speech-language pathology for over 25 years and has written on the subject.  He has presented seminars on a variety of topics at various state, ASHA, and international conferences and conventions and has lectured around the globe, including the USA, Canada, Singapore, Australia, and New Zealand.

Paul is married to Carol Fogle, RN, a former emergency room nurse and now a critical care nurse.  He has an adult daughter, Heather.

Lynda J. Reece, M.A., CCC-SLP, received her M.A. in speech-language pathology at the University of the Pacific in 1988.  She worked for three years at the Scottish-Rite Language Center in Stockton, California, where she developed the center's program for children with attention deficit disorders, central auditory processing disorders, and learning disabilities.  She has presented numerous in-services and seminars throughout California and in a variety of cities around the country on those topics.  She worked as a therapist and facility rehabilitation director in skilled nursing facilities for almost ten years and now is the director of the speech-language pathology services at the Senior Center in Stockton, California.  She is an annual invited lecturer on the topic of dysphagia at the University of the Pacific.  Currently, Lynda provides speech and language therapy at Keyes and Denair Unified School Districts.  She also does some private practice work and consulting.

Lynda has three adult children: Anthony, a marriage, family, child counselor; Holly, who is a physician's assistant; and Katie, who is an elementary school teacher.

Jeanine F. White, B.S., OTR, is an occupational therapist whose career has been as full of contrasts as the countries in which she has lived.  After completing her occupational therapy clinical training at San Jose State University in California in 1971, she moved with her husband to Beirut, Lebanon.  There she worked privately as an occupational therapist and taught in the Lebanon Evangelical School for the Blind.  She volunteered in the Baptist Hospital in Ajloun, Jordan, before returning to the U.S.  She worked for two years as a staff therapist at Pacific State Hospital (now Lanterman Hospital), working with children who had multiple disabilities.

Jeanine lived in Bangladesh for ten years, where she did volunteer work for individuals who had hand injuries.  She provided a sensory integration program for the school her children attended.  Jeanine also worked for two years in the Centre for the Rehabilitation of the Paralyzed with people whose lives had been devastated by accidents resulting in spinal cord injuries.  She later moved with her family to Thailand, where she was invited by staff at the Chiang Mai University Occupational Therapy Department to assist in supervising students in their hands-on training in pediatrics.

Upon returning to California, Jeanine began working as a staff therapist in skilled nursing facilities, later becoming an occupational therapy supervisor and clinical specialist.  For eight years, Jeanine worked in a medical therapy unit with children within California Children's Services.  Currently, she works with adults who have had brain injuries in Gentiva's Rehab Without Walls, and with children birth to three years old with a private agency, Able Beginnings.


Practical (functional) problem solving in rehabilitation is concerned with activities of daily living (ADLs).  Developing successful practical and functional problem-solving skills that may be important to the patient's well being and safety is a priority to all rehabilitation specialists, medical staff, and hospital administrators, as well as family and friends.  This priority is the same for the newly-admitted patient (regardless of the age), the long-term patient, and the patient who is being prepared for discharge to a lower level of care or discharge to home and community.

Patients with a variety of neurological and cognitive impairments often display poor practical problem-solving skills at all levels, such as awareness, understanding cause and effect, and recognizing appropriate courses of action.  According to Emlet, Crabtree, Condon, and Treml (1996); Pedretti, Smith, and Pendleton (2006); and Sohlberg and Mateer (2001), the problem may be the result of impulsiveness, decreased insight into the disability, impaired judgment, or a combination of these.  Decreased insight, disorientation, and impaired memory can contribute to a patient's inability to recognize personal limitations for specific situations.  A patient's ability to communicate and appropriately manage practical problems in his environment reflects his cognitive-linguistic status and his potential for discharge to home or a lower level of care.

Cherney and Halper (1999); Halper, Cherney, and Burns (1996); Myers (1999); and Tompkins (1995) discuss the cognitive-communicative problems after right-hemisphere damage.  In the cognitive areas, they stress impaired attention, perception, memory, organization, reasoning, and problem solving.  In the area of communicative impairment, pragmatic skills are notably disturbed.

Cognitive and communicative disorders may be the result of other than neurological impairments.  Fogle (1996) and Ross-Swain and Fogle (1996) discuss respiratory, circulatory, and metabolic problems that may result in cognitive and communicative disorders in the elderly.  These same problems also may affect cognition and communication in other age groups.

In a hospital, a patient needs functional problem-solving skills in order to manage himself appropriately and safely in his room and bathroom; to deal with assistive devices, such as wheelchairs, walkers, and canes; and to be aware of and manage possible swallowing difficulties.

At home, the patient may have many of the same practical problem-solving concerns as he had in the hospital, but with more expectations and requirements for independence.  Other practical and safety issues may arise from managing his own medications, negotiating floors and stairs, working appliances, and handling home security issues. In the community, the person may need to deal with inclement weather and manage himself in crowded stores and busy restaurants.

Functional problem solving is an essential part of independence.  According to Chapey (2001), problem solving requires five mental operations:

  1. Cognition, the basis of all other operations, involves awareness, knowing, immediate discovery (or rediscovery), and recognizing information in various forms (comprehension or understanding).
  2. Memory is the power, act, or process of fixing newly gained information in storage.
  3. Convergent thinking involves generating logical conclusions from information, with an emphasis on achieving conventional best outcomes.
  4. Divergent thinking involves generating logical alternatives from information, with an emphasis on the variety, quantity, and relevance of the output.
  5. Judgment involves using knowledge to make appraisals or comparisons, or to formulate screenings based on known information.

Ylvisaker, Szekeres, and Feeney (in Chapey, 2001) stress functional-integrative performance of "real-life" tasks and activities that involve a complex interaction between the environment and the entire cognitive mechanism, personality, and motivational variables.  Emlet et al. (1996) emphasize the need to assess and, when possible, treat elderly individuals in their home environments.  Brookshire (2007) says treatment of reasoning and problem solving impairments entails structured practice in a variety of tasks that require reasoning, foresight, and problem-solving, such as role-playing situations, proposing solutions to problems posed by the clinician, and planning activities for ADLs.

Brookshire recommends a formal, prescriptive, highly-structured approach to problem solving:

  • Identify the problem.
  • Think of several possible solutions.
  • Evaluate the feasibility and potential consequences of each solution.
  • Choose the best solution.
  • Apply it.
  • Evaluate the results.

Marshall, Karow, Morelli, Iden, and Dixon (2003) discuss the use of the Rapid Assessment of Problem-solving (RAPS), a modification of Mosher and Hornsby's (1966) Twenty Questions Test (20Q).  Problem solving is frequently considered a component of executive functions (Murray & Ramage, 2000; Purdy, 2002) and comes into play when habitual or automatic behavior is insufficient to attain a desired goal (Ylvisaker et al., 2001).

Several standardized instruments assess the problem-solving abilities of brain-injured individuals in clinical settings, such as the Wisconsin Card Sorting Test (Grant & Berg, 1948), the Porteus Maze Test (Porteus, 1965), and Coloured Progressive Matrices (Raven, Court, & Raven, 1984).  Marshall et al. (2003) say that some writers have questioned the validity of formal problem-solving measures, and that patient motivation to perform on some tests of executive functioning may be low because there is no obvious relationship between the test and past experience (Burgess, Alderman, Evans, Emslie, & Wilson, 1998; Kafer & Hunter, 1997; Laine & Butters, 1982; Lezak, 1983; Mertz-Garcia & Stick, 1986; Shallice, 1982).

More recently, some instruments have been developed to assess functional problem solving, such as the Multiple Errands Test (Aitken, Chase, McCue, & Radcliff, 1993), the Six Element Test (Shallice & Burgess, 1991), the Everyday Problem-solving Inventory (Cornelius & Caspi, 1987), and the Behavioral Assessment of the Dysexecutive Syndrome (Wilson, Alderman, Burgess, Emslie, & Evans, 1996).  None of these instruments, however, focus on problem solving for safety in the hospital and home environments.

Newer assessment instruments, such as the Ross Information Processing Assessment-Geriatric (RIPA-G) (Ross- Swain & Fogle, 1996) and therapy materials such as WALC 5 Neuro Rehab (Arnold, 2003), the Functional Skills Program for the Neurologically Impaired Client (Wamboldt, 1996), the RIPA-G Treatment Manual (Ross-Swain & Yee, 1998), Critical Thinking for Activities of Daily Living and Communication (Daly & Fouche, 1998), Functional Learning for the Home and Community (Peterson & Villegas, 1998), and Retraining Cognition-Second Edition (Parente & Herrmann, 2003), increasingly incorporate questions and items dealing specifically with patient/client functional and safe problem solving in the home and community environments.

The following questions may be important to clinicians when choosing a clinical measure (Marshall et al., 2003):

  • Are the test instructions and requirements sufficiently simple to be understood by patients with a wide range of abilities?
  • Will the instrument sustain the patient's interest and motivation such that he or she will perform it?
  • Does the test have some relationship to the patient's past experience?
  • How much examiner training is needed to administer the test?
  • Can the test be administered and scored rapidly?
  • Can the test be given to patients who demonstrate a range of abilities at various points in the post-onset course?

According to Schlageter and Zoltan (1996), cognitive deficits are related to eventual independence in self-care and discharge disposition.  Mateer (2002) says that cognitive problems of mild traumatic brain injury may not become apparent until the person returns to work and begins dealing with challenging cognitive tasks.  In order for a patient to be discharged to home or a lower level of care, the rehabilitation and nursing staff need to be confident of the patient's ability to function at reasonably independent levels.

The Source for Safety Cognitive Retraining for Independent Living is designed to help individuals increase their participation in life by improving their abilities to safely carry out activities in their pursuit of independence and enjoyment of life.  This resource includes the evaluation and therapy for these common areas of concern in the hospital, home, and community environments:

  • room/bedroom and bathroom
  • wheelchairs and assistive devices
  • swallowing and diet
  • medications and health
  • floors and stairs
  • kitchen and appliances
  • home safety
  • community–outside
  • community–inside
  • general precautions