Complaint Investigation Report

LPA Smith interview with staff revealed that 3:1 not always maintained during some shifts. Information revealed from the interviews confirmed the facility is understaffed and the facility affected by high turnover of personnel.

Based on the information gathered during previous licensing visits, observation, and interviews there is a sufficient pertinent information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Staff did not meet the minimum qualifications

It was alleged that staff did not meet the minimum qualifications. Overall interviews with the staff confirmed that some staff are not completely finished with trainings required by position. A review of personnel files revealed training information and specific training topics and hours for 11 out of 22 staff records were missing or incomplete. First Aid/CPR, CPI training and training certificates were expired or not available for at least seven (7) staff members.

Based on the information gathered during this and previous licensing visits and interviews there is sufficient pertinent information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. No citation was issued at this time. The facility was cited for this issue during Case Management Deficiency visit conducted on 08/24/2022

Staff did not properly report an incident involving a client

It was alleged that staff did not properly report an incident involving a client #1 (C1). LPA Smith interview with administrator revealed that administrator did not report or was not aware of what incidents should be reported to the Licensing office. During review of facility documents obtained on 07/15/22 and on 08/19/22 and from a review of R1 medications LPA discovered several incidents posing hazards to C1’s health and safety were not reported to the Licensing Department.

Based on the information gathered during this and previous licensing visits, interviews there is sufficient pertinent information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Please issue citation under the reporting requirements.