Facility Evaluation Report

Licensing Program Analyst (LPA) conducted a Case Management visit regarding concerns identified during a complaint investigation involving the handling of client Personal and Incidental (P&I) funds.

During the investigation, LPA identified deficiencies related to the handling, authorization, and documentation of client P&I funds. The investigation revealed that Client 1’s (C1) P&I account was $14.00 short for a reported cigarette purchase. No receipt was available, and the transaction was not properly documented on C1’s P&I ledger. The investigation also revealed that on 12/24/2025, Staff 1 (S1) purchased items for Client 1 (C1), Client 2 (C2), and Client 3 (C3). S1 later requested reimbursement of $18.00 from each client’s P&I funds. C3 was not present during the shopping outing. Client interviews revealed that the clients were not fully informed of the deductions before the money was taken from their P&I accounts. Review of records also showed that the transactions were not properly documented on the clients’ P&I ledgers, and receipts were not provided to the clients. Staff 2 (S2) stated that while preparing P&I funds for a subsequent outing, S2 observed a “cash out” entry on the clients’ ledgers. When S2 asked the clients about the withdrawal, the clients stated they were unaware that $18.00 had been taken from their accounts. The Administrator acknowledged the improper handling of the clients’ P&I funds and took corrective action. C1 was reimbursed $14.00 for the undocumented cigarette purchase. Additionally, C1, C2, and C3 were each reimbursed for $18.00 for the purchases that were made without proper client authorization and documentation.