Complaint Investigation Report

It was determined that C1 did not meet the criteria to be admitted for evaluation. After emergency personnel left the facility, C1 had another increase in agitation and aggression and hit C2 in the chest with a closed fist. Facility staff separated the two clients and C1 was transported to the Crisis Stabilization Unit. Review of C1’s file indicated that C1 was to utilize coping mechanisms if they were feeling angry or dealing with frustration and stress. Staff interviews conducted stated that the level of supervision for clients depends on the support clients need and is determined by hospital assessment and by the facility’s intake assessment upon admittance to the program. Review of Facility’s Plan of Operation states the following: “at least one staff member shall be present at any time there are clients at the facility. A greater number of staff shall be present during times when there are greater numbers of clients in programmed activities… staff/client ratio shall be at least one full-time equivalent direct-service staff for each 2.5 clients served.” The plan of operation also states, “a minimum of two staff counselors will always be on duty and often three or more staff members will be present during the day and evenings when there are more activities and case management services offered and provided." Review of Facility's Time Sheets indicated that there were two staff members on-site during the incident.

Based on record review and interviews conducted, the LPA is unable to determine if a Title 22 Regulation Violation has occurred. Therefore, this allegation is Unsubstantiated .

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Program Director. Signature on form confirms receipt of documents.