Complaint Investigation Report

The report consisted of a Notice of Noncompliance and a Plan of Correction (POC). LPA confirmed with Executive Director, DHCS, had conducted a visit. According to S1, she conducted her own review of the admission agreement a few days later after client's entry and found a representative signature was missing. S1 immediately had representative sign admissions agreement. Based on interviews and records review there is sufficient information to support this allegation. Therefore, this allegation is deemed to be SUBSTANTIATED at this time.

Allegation # 2: Licensee failed to properly develop a treatment/rehabilitation plan for resident(s).

It is alleged two (2) open client treatment/rehabilitation plans did not contain documented evidence that they were prepared with the client. LPA review of DHCS report and confirmation from S2 that two open clients did not sign plans but they did assist in treatment plan. Information was noted on the comments section of the plans with date and time client met with representative with no signature. Based on interviews and records review there is sufficient information to support this allegation. Therefore, this allegation is deemed to be SUBSTANTIATED at this time.

Allegation #3: Staff failed to review client's treatment/ rehabilitation plan at least weekly.

It is alleged one (1) open client treatment/rehabilitation plan was not completed at least weekly. LPA review of DHCS report and confirmation from S1 that one (1) open client completed plan on the 8th day. Based on interviews and records review there is sufficient information to support this allegation. Therefore, this allegation is deemed to be SUBSTANTIATED at this time.

Allegation #4: Licensee failed to document staff training.

It is alleged that staff did not have evidence of completed training for preparing various documents in the facility. LPA reviewed the report from DHCS, and S1 confirmed although they are a licensed professional, training for completing various documents was not completed and not on file. Based on interviews and records review there is sufficient information to support this allegation. Therefore, this allegation is deemed to be SUBSTANTIATED at this time.

Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Copy of report emailed to Executive Director.