Complaint Investigation Report

It was also reported that Two of six staff members did not receive hands-on training in first aid and cardiopulmonary resuscitation (CPR) by a certified instructor on an annual basis. LPA obtained documentation for two of six staff members where First Aid ad CPR expired for a period of several months. Staff members have since been enrolled in First Aid/ CPR and are current.

All staff are currently Crisis Prevention Intervention (CPI) certified but three of six staff did not receive monthly emergency intervention refreshers training for one month and one of six staff had not received emergency intervention refresher training for two months. AD stated the Personnel Report (LIC 500) will be updated monthly to ensure all staff receive their twenty minute CPI refresher trainings.

It was reported that Individual Behaviors Support Team (IBST) meeting documentation, reviewed from May 2025 to October 2025, was reviewed and client and Client's Rights Advocate (CRA) documentation did not consistently document if client or CRA were participating in the meeting. AD will work with staff to provide consistent IBST documentation.

It was reported the facility approved staff rates that did not match the individualized clinically recommended number of staffing needs or consultation hours Upon interview with the AD, the facility was providing more staff and consulting hours than recommended. AD stated that the staffing ratios were resolved during the Semi- Annual. Consult hours for physical therapy will also be monitored and adjusted to the clinical recommendation.

Based on LPA's record review and interviews, the preponderance of evidence standard has been met, therefore the allegations that: Facility evaluation report was not maintained on file for review,

Licensee did not ensure client's Individual Behavior Support Plan included all requirements established in Title 17, Licensee did not ensure staff received hands-on training in first aid and cardiopulmonary resuscitation, The licensee did not ensure that a direct care staff person renews the emergency intervention training annually, The licensee did not involve the client in the development of the needs and services plan and the licensee did not meet the staffing requirements as specified by the regional center are Substantiated.