Complaint Investigation Report

R1, R2 and R3 had a physician visit on March 9th, 2022 and telephone physician visit on 3/25/22 with a potential new Primary Care Physician (PCP). Staff indicated that numerous efforts to ensure that appointments were being scheduled timely were attempted but proved to be unsuccessful as calls were not returned or emails were not responded to by the physician’s office. The house manager confirmed that the residents were late for their 60-day physician visits and have since met with the physician to ensure compliance. Therefore, based on the interviews and documentation review , it was confirmed that the required physician visits were not met and this allegation is deemed Substantiated at this time.

Regarding the allegation: Staff did not meet the minimum qualifications required: it was alleged that this facility was not meeting the required Direct Support Professional training (DSP I) and/or (DSP II). Interviews and documentation review confirmed that the required DSP training was not yet met. Staff interviews confirmed that training was in process and not completed. Records review confirmed that Staff #1, Staff #2 and Staff #3 had not completed all DSP training. Staff #1 completed DSP I training on 3/18/2022 and is now eligible to schedule DSP II training. Staff #2 is overdue for DSP I and DSP II training and records reflect that DSP I was last completed on 1/31/2020 and DSP II was last completed 3/6/2020. Staff #3 completed DSP I training on 2/8/2020 and DSP II training on 12/17/2021. Staff #4 and Staff #5 do not have updated DSP training information available. The house manager indicated that staff training was assumed to be completed and has not been reviewed, as the house manager came on board in October 2021. Based on the information obtained, this allegation is deemed Substantiated at this time.