Complaint Investigation Report

Regarding the allegation that facility staff did not properly document manual restraint debriefings: it was alleged that the manual restraint debriefing logs from April 2025 through September 2025 did not consistently document consumer involvement or the date and time that the debriefing occurred. PM admitted the allegation, stating that for C1’s manual restraint debriefing logs for April 19, 2025, C1 was hospitalized and could not participate in the manual restraint debriefing but this was not documented on the manual restraint debriefing logs, although PM did speak to C1 every day while C1 was in the hospital and completed the debriefing which was not documented. LPA reviewed C1’s manual restraint debriefing logs from April 2025 through September 2025 and noted the four manual restraint debriefing logs for April 19, 2025, do not document the date and time of the debriefing or C1’s refusal or inability to participate. The information obtained corroborated the allegation.

Regarding the allegation that the licensee did not ensure staffing ratios were met: it was alleged that the September 2025 schedule did not meet the staffing ratios for C1 and C2. PM admitted the allegation, stating that there were instances when the facility did not meet staffing ratios, and there were other times when managers were covering shifts, but the managers covering shifts was not documented on the schedule. LPA reviewed C1’s needs and services plan which states they require two staff assigned to them 24 hours a day and C2’s needs and services plan which states they require one staff assigned to them 24 hours a day. LPA reviewed the facility’s staff schedule for September 2025 which shows that the facility did not meet the staffing ratios for certain shifts on multiple days in September as documented on the bottom three columns of the schedule. The information obtained corroborated the allegation.

Regarding the allegation that the licensee did not follow the plan of operation: it was alleged that S1 did not have documentation of 25 hours of continuing education from May 2024 through May 2025 as required by the facility’s plan of operation and instead had only 22.75 hours of documented continuing education. LPA reviewed the facility’s plan of operation, which states that direct care staff shall complete a minimum of 20 hours of continuing education annually as well as five hours per year of training in person-centered planning, positive behavior supports, trauma-informed care, and cultural competency. LPA reviewed S1’s training records which show they received 20.96 hours of continuing education from May 2024 through May 2025. The information obtained corroborated the allegation.