Complaint Investigation Report

Regarding the allegation that staff did not prevent residents from engaging in inappropriate behavior using illegal drugs. Based on interviews with 5 out of 5 staff, staff reported during intake they review all client’s belongings and wash their clothes. The department received an LIC 624 on 07/04/2022 reporting that C1 had brought in fentanyl stored in their rectum into the facility. The facility was only made aware when the client self-reported after C1 had an incident with the drug. Facility staff then submitted the Unusual Incident Report LIC 624 to the Department. Based on clients’ interviews 4 out of 5 clients reported that they do not have access to drugs while in care, the final client reported they witnessed it outside of the facility.

The allegation that staff did not prevent clients from wandering from the facility. Based on interviews with Program Director Erin Franco reported that there has only been 1 elopement, which the facility self-reported on 03/07/2022. Interviews with 4 out 5 clients revealed the clients would need prior approval to leave the facility or they would be escorted by facility staff.

For the allegation the staff did not keep resident’s personal information confidential. Based on interviews with 4 out 5 clients, all reported they felt their information was safeguarded. In interviews with 5 out of 5 staff all staff indicated client’s records are kept electronically and there is no paper documents.

Regarding the allegation staff are falsifying residents’ documents. Based on interviews with 5 out of 5 staff, all documents are scanned into the system directly as is and discard by shredding. It was alleged that the client signed for their conservator, however the LPA observed no clients being under conservatorship.

For the allegation staff are not properly reporting incidents regarding residents, the referenced incident on 03/15/2022 where client hit the staff was reported to the department on 03/16/2022.

Based on the preponderance of evidence the allegations facility staff did not prevent residents from engaging in inappropriate behaviors, staff did not prevent residents from wandering from the facility, staff did not keep residents personal information confidential, staff are falsifying residents documents, and staff are not properly reporting incidents regarding residents are found to be UNSUBSTANTIATED, meaning although the allegations may have happened or is valid there is no preponderance of evidence to prove the alleged violations did or did not occur. This agency has investigated this complaint and an exit interview was conducted with facility and a copy of this report and LIC 811 was provided at the time of exit.