Complaint Investigation Report

Regarding the allegation that the licensee shall provide a full copy of the current admission agreement to the client: it was alleged that the files for Client #2 (C2) and Client #3 (C3) did not contain documented evidence that these clients received a copy of the house rules on admission. LPA interviewed CM who denied the allegation, stating that all clients sign admission agreements and house rules acknowledgments which indicate that by signing the client confirms receipt of copies of these documents. LPA reviewed the admissions agreements for C1, C2, and C3 and noted the admission agreement indicates that by signing clients confirm that they have received a copy of the admissions agreement. However, LPA also reviewed the Client Handbook & Residential Client Guidelines Receipt and Acknowledgments for all three clients which state that by signing clients acknowledge that they have a right to receive a copy of the client handbook and/or residential client guidelines, but do not document that the clients have actually received these documents. The information obtained corroborated the allegation.

Regarding the allegation that the needs and service plan is incomplete: it was alleged that client files for Client #1 (C1) and C2 did not contain assessments of their vocational limitations. LPA interviewed CM who stated that the facility does assess clients’ vocational limitations. LPA reviewed the Biopsychosocial Assessments for C1, C2, and C3 and noted that the only vocational question is whether they are currently employed. However, this one question does not assess the clients’ vocational limitations and what supports they need to achieve their vocational goals. The information obtained corroborated the allegation.

Regarding the allegation that the Treatment/Rehabilitation plan was not updated as necessary to ensure accuracy: it was alleged that the Treatment/Rehabilitation Plan for C2 was not updated and reviewed at least once every 30 days. LPA interviewed CM who stated that C2 was admitted on April 3, 2025 and C2’s Treatment/Rehabilitation Plan was updated on April 17, 2025 and then again on May 20, 2025. LPA reviewed the facility’s plan of operation which states that the Treatment/Rehabilitation Plan must be updated every 30 days. In this case, C2’s Treatment/Rehabilitation Plan was updated more than 30 days after the last update. The information obtained corroborated the allegation.