Complaint Investigation Report

Allegation: Licensee did not ensure facility has clearance for non-ambulatory clients

It was alleged that the facility did not have a clearance for non-ambulatory clients, and one (1) out of four (4) clients was using a wheelchair. To investigate this allegation, LPA conducted an interview with four (4) out of four (4) clients and all clients confirmed that the facility has a client that uses a wheelchair (20-30%) of the time and mostly when taken for an outing. Moreover, all clients also informed the LPA that C1 uses the wheelchair, occasionally, inside the facility for couple of hours. LPA also conducted a review of C1’s Physician’s Report, and in an “Ambulatory status of a client” section it indicated that C1 is Non-ambulatory. Lastly, LPA reviewed a Fire Clearance granted on 03/22/24, and observed that the facility is approved for six (6) Ambulatory clients only. Based on information gathered during today’s visit this allegation is Substantiated.

Allegation: Staff are not trained for non-ambulatory clients

It was alleged that the staff are not trained for non-ambulatory clients. To investigate this allegation, LPA conducted an interview with the Program Director and a Clinical Program Director and was informed that prior to C1 moving to this facility an email was sent to all facility staff members regarding C1’s condition and what to expect when seizure episodes occur. However, no actual in-house training was conducted, and no staff training certificates were available. Based on interviews and record reviews this allegation is Substantiated.

Allegation: Licensee did not ensure facility is wheelchair accessible for non-ambulatory clients

It was alleged that the facility is not wheelchair accessible. To investigate this allegation, at 10:50am LPA conducted a physical tour of the facility and did not observe the facility installed a wheelchair accessible entrance and or had various portable ramps. Interview with the Program Director and a Clinical Program Director revealed that C1 was using a wheelchair at times. Moreover, interviews with all four (4) clients confirmed that, occasionally, C1 does use a wheelchair inside the facility. Interviews also revealed that on 04/24/24 the facility ordered a ramp and it was placed in C1’s room during today's visit. Lastly, LPA reviewed a Fire Clearance granted on 03/22/24, and observed that the facility is approved for six (6) Ambulatory clients only. Based on LPA’s observation and interviews gathered during today’s visit this allegation is Substantiated.