Complaint Investigation Report

LPA investigated the allegation that staff are not properly trained. Per DHCS report dated May 30, 2024, one staff member did not have documentation of having the twenty hours of in-service training. LPA reviewed five of five staff Relias Training records. One of five Relias staff records show Staff #1 (S1) had 19.3 training hours. Thus the twenty hour requirement was not met.

A Plan of Correction was submitted to DHCS and a Staff Plan of Supervision, Training, In-Service training form is now being utilized by the facility. The facility will address the requirement of not having one year experience as follows. One week prior to on boarding, Clinical Director will implement a Plan of Supervision for employees who do not meet the year requirement and fill in the gap with weekly training. The Program Administrator will also audit the Plan of Supervision on a quarterly basis. LPA reviewed S1's training for 2025 and S1 had 49.8 hours of documented training.

The Plan of Correction for staff are not properly trained will be addressed by the Office Coordinator reviewing employee Relias training monthly and the Clinical Director will fill in any training gaps to meet the twenty hour in-service requirement. The Program Director will work with staff who do not meet this requirement with disciplinary action, as needed.

LPA obtained the following documents: Client rosters from May 30. 2024 and June 12, 2024. LPA obtained and reviewed six of six client files from June 2024. LPA also obtained five of five current client medical assessments for review. Per DHCS report dated May 30, 2024, two of six client Medical Assessments were not signed within thirty days of admission by a licensed clinician. The facility submitted a Plan of Correction from June 29, 2024 that the physician will meet with the client within twenty-four hours of intake and would submit the medical assessment within the thirty days required.

LPA reviewed the six client files from June 2024 and noted all signatures and information were corrected. LPA also reviewed five of five current client files and clinician signatures were noted and all assessmenst were complete at this time.