Complaint Investigation Report

Regarding the allegation that Facility did not ensure that sufficient staff are at the facility whenever clients are present, the following has been concluded: Based on a review of the provisional facility schedules cross-referenced with the time management logs provided and staff interviews conducted, it was confirmed that a minimum of one staff member present was ensured for each of the three daily shifts. The time tracking management system did not differentiate between this licensed location and licensed location 306006279, however LPA was able to verify that no commingling of staff was taking place between locations.

Regarding the allegation that Facility did not ensure that a written Needs and Services Plan is completed prior to or within 72 hours of admission, the following has been concluded: Based on a review of client records for currently admitted individuals, all clients are confirmed to have an approved and signed Needs and Services Plan in place. For one of the individuals in care, it was determined that the Needs and Services Plan was generated within the required 72 hours but only received the therapist signature 24 hours later. Facility staff indicated that this is not a typical occurrence and that facility policy is to initiate the Needs and Services Plan as soon after admission as possible and to gather all signatures within the 72-hours window. A Technical Assistance Advisory Note to that extent is issued during the visit.

Regarding the allegation that Facility did not ensure staff received a minimum of 20-clock-hours of continuing education per year, the following has been concluded: The facility uses Relias for training and tracking of completed modules. Logs were provided for all current staff members scheduled at this licensed location and evidenced both initial and annual training being provided on the required topics in the required quantity. Timestamps associated with the completion appear to indicate that more than 20 hours of training were completed on given days for some staff members, however facility staff interviews determined that it was a result of the way completion is tracked and not a reflection of the actual training being dispensed.

Based on the review of records, facility visit and interviews conducted, the three allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.