Complaint Investigation Report

Regarding the allegation it was reported treatment/ rehabilitation plans reviewed for three (3) client records did not contain documented evidence of ongoing review of progress towards reaching established goals. To investigate the allegation LPA conducted an interview with Marine and Armen. At 10:18 a.m. LPA reviewed electronic records of one (1) out of five (5) current client written treatment/rehabilitation plans specifying goals and objectives. According to Marine at the time when Department of Health Care Services (DHCS) conducted their visit, the then clients progress was only documented in the progress notes viewable to the the therapist only. Client signature were obtained when they would meet with the therapist to discuss their progress. According to Marine, the Department of Health Care Se rvice s wanted to see documentation of clients progress in the comment section of the records they use when they meet with clients. LPA observed the comment section is viewable by the client giving them access to view what progress or lack of progress they are making towards their goals. Five (5) out of five (5) current client records have ongoing notes documented in the comment section of their treatment/rehabilitation plans. Based on interviews and review of the summary report by DHCS the allegation is substantiated at this time.

Allegation #2: Staff did not meet the minimum qualifications to provide direct service to client(s). Regarding the allegation it was reported that four (4) personnel records did not contain documented evidence that the employees had one (1) year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities or a documented plan of supervision. To investigate the allegation LPA conducted an interview with Marine and Armen. LPA reviewed training documentation for one (1) staff and found staff training to be ongoing and documented with the topic covered and staff signature. However, the record did not have on file a s pecific plan of supervision and in-service training for the employee which will guarantee the ongoing qualification of the employee to perform the job. The plan should include but not be limited to the frequency and number of hours of training, the subjects to be covered, and a description of the supervision to be provided. According to Armen, the staff training meets the in-service training for the employee for ongoing qualifications. Although there is documentation of completed training there is no documentation of the specific plan of supervision. According to Marine, DHCS would want them to meet with staff one on one on an ongoing basis to discuss progress towards qualification. Based on interviews and review of the summary report by DHCS the allegation is substantiated at this time.

Deficiency's cited (refer to LIC9099-D). Appeals provided. Copy of report provided.