Complaint Investigation Report

During record review, LPA Haddadin verified staff training documentation, including Direct Support Professional (DSP) certifications for each staff member. Staff 1 (S1) held DSP-1 certification dated April 8, 2005, and DSP-2 certification dated June 5, 2007. Staff 2 (S2) held DSP-1 certification dated December 13, 2020, and DSP-2 certification dated March 25, 2025. Staff 3 (S3) held DSP-1 certification dated November 6, 1999, and DSP-2 certification dated August 4, 2001. Staff 4 (S4) held DSP-1 certification dated November 6, 1999, and DSP-2 certification dated August 4, 2001. LPA Haddadin noted the DSP training documentation included training related to medical records, diabetes care, and medication administration. Staff training records also reflected completion of “Best Practices in Monitoring Client Blood Sugar” on August 30, 2024, a two-hour training provided by a BSN nurse Consultant. Records further reflected an additional training provided by BSN nurse Consultant dated September 12, 2024.

LPA Haddadin was unable to interview the clients in care because, due to their medical conditions and non-verbal status, LPA Haddadin could not obtain reliable statements. During the visit, LPA Haddadin observed S1 administering medications to current clients and observed that S1 followed required procedures consistent with DSP training. LPA Haddadin also reviewed Client 1 (C1), a former client of the facility, and confirmed physician orders and medications were followed and documented in the client’s file. Additionally, LPA Haddadin reviewed records for all current clients and confirmed physician orders, including medication orders, were documented in client notes and that medical records for all current clients were maintained accurately, including the records reviewed for C1.

Based on interviews, observations, and record review, the allegations “Facility staff is testing glucose without meeting required conditions,” “Licensee is not keeping accurate medical records,” “Licensee is unable to verify staff trainings,” and “Licensee is not following the physician’s orders for the resident” were determined to be unsubstantiated. Although the allegation may have occurred or may be valid, there was not a preponderance of the evidence to prove or disprove that the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report was provided to the Licensee.