Complaint Investigation Report

The plan of operation notes that physician oversight and approval is required to release medications to clients that voluntarily leave treatment prior to clinical recommendations. There was no documentation confirming that the medication was or was not released per charting notes. None out of the thirteen staff was able to confirm if the medication was or was not released to C1 at discharge.

Regarding the allegation, Client was not provided medical attention in a timely manner, it was alleged that a staff had been informed about their swollen eye "days before" going to the clinic on June 24, 2022. LPA attempted to interview the staff in question, however the call was not returned. Based on the review of the chart summary, there were no records noted regarding C1's swollen eye.

Regarding the allegation, Lack of staff to meet the client's needs, it is alleged that there were insufficient staff resulting with little to no group therapies due to the group facilitators being terminated. Based on the review of case manager discharge summary dated June 28, 2022, C1 received a minimum of 36 hours of group therapy sessions per 7 days and two individual therapy sessions a week. Based on the review of C1's charting, C1 was admitted Wednesday, June 15, 2022. C1 received their first 1:1 session on Tuesday, June 21, 2022. The following 1:1 session was on June 24th with a total of 14 group therapy sessions between June 22nd to June 27th. Based on the review of the resident roster, when C1 was admitted to the facility on June 15, 2022, six clients were registered to the facility. Based on the review of the staff schedule, there were two staff for the morning and afternoon shifts with one staff in the evening shifts.

Due to conflicting information obtained, the following allegations: Facility did not provide client medication prior to leaving, Client was not provided medical attention in a timely manner, and Lack of staff to meet the client's needs are deemed UNSUBSTANTIATED as there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted with Program Director Andrew Crawford and Administrator Michael Villareal by telephone, and a copy of this report was provided at exit.