Complaint Investigation Report

Per record review, LPA Rodriguez observed that the facility has a weekly activity schedule and the first activity begins at 9:00AM, and activities will run until 10:00PM. It was also observed that the facility documents each client’s daily attendance for each activity via digital database (Kipu). During this visit, LPA Rodriguez observed clients socializing with each other, and engaging in activities.

It was alleged that facility staff is not properly trained. LPA Rodriguez conducted a total of 5 interviews which consisted of clients and staff. 4 out of the 4 client interviews did not corroborate with the allegation by stating that the facility staff are “good” and “knowledgeable”. 1 out of the 1 interview conducted with staff did not corroborate with the allegation by stating that each staff member will complete 20 hours (or more) of training which consist of: First-Aid, crisis prevention intervention, personal rights, client rights, supervision, intake and discharge process. Per record review, LPA Rodriguez observed that the current staff present at the facility, have completed the required trainings prior to caring for clients.

It was alleged that facility is not following their Plan of Operation for client discharge. LPA Rodriguez conducted a total of 5 interviews which consisted of clients and staff. 4 out of the 4 client interviews did not corroborate with the allegation. 1 out of the 1 interview conducted with staff did not corroborate with the allegation by stating that the process for a client’s discharge includes completing a discharge summary, aftercare plan, harm risk assessment, medication transfer and resource information. Per record review, the current clients present at the facility have not completed a discharge plan due to recently being admitted into the facility this month. LPA Rodriguez conducted a review of the discharge plan for past clients, and observed that the discharge protocol was completed, dated and signed.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted with S1 Mitrovich, and a copy of this report was explained, and provided.