Complaint Investigation Report

LIC500, Client Roster, House Rules, Admission Agreement, Placement Information Sheet, Physician’s Reports, Appraisal/Needs and Services Plan, Recreation Therapy Monthly Reports for 04/2023 to 06/2023, Placement Information Sheet, Crisis Prevention Plan, Medications consent form, Identification and Emergency Contact form, SIR's, most recent START CSCPIP, emails and/or correspondences related to C1's behaviors.

LPA, S1 and S2 toured the facility and C1's bedroom. There were not any blocked passageways leading to C1's bedroom or throughout the facility. Sofas, chairs, tables and bean bags were present in the common areas. Interviews with S1, S2, S3 and S4 revealed that C1 has destructive behaviors that include property damage and moving of the bean bags. S1 stated when C1 feels unsafe, C1 will retreat to C1's bedroom and/or advise S1, S2, S3 or S4 that he/she needs to go outside or go into his/her room. In an effort to not restrain C1 when C1 moves the bean bags and exhibits aggressive behaviors, the staff will remove the barrier of bean bags that C1 has created to feel safe once C1 has calmed down. C1's bedroom has an alternate access via a sliding door and there does not appear to be a fire hazard while C1 is being redirected. The interview with W4 further revealed that RCEB case notes from 07/14/23 stated that S1 and W2 are currently working on alternative behavioral services for C1. C1 was outside, lounging on the patio furniture during the visit. LPA attempted to interview C1, but C1 was not responsive.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided to ADM.