Complaint Investigation Report

On 12/5/2024 and 12/23/2024, LPA conducted interview with Staff and Administrator. Of the 5 staff interviewed, each of them stated a need for supervision of Client 1 (C1) during times when C1 is up ambulating was identified. Per AD and staff, C1's need for supervision was communicated to the Direct Service Providers (DSPs) from Administrator. AD stated that when C1 is up and ambulating they are at risk of falling and sustaining an injury due to their walking gait or due to seizures. AD stated that C1 gets up to ambulate at anytime. AD also stated that C1 may experience seizures at anytime as well. Due to the potential for C1 to ambulate at anytime and experience seizures at anytime, the LPA determined C1 requires monitoring 24 hours a day. Of the 5 staff interviewed, 4 of them stated C1 has a direct 1-on-1 (D1) staff through the Adult Day Program (ADP) that C1 attends. Of the 5 staff interviewed, 3 of them stated C1's ADP D1 works with C1 for 8 hours a day in the morning and afternoon.

Per AD, the facility has 2 DSPs working during night shifts and 2 DSPs working during overnight (NOC) shifts. LPA verified this via the staff schedule for September 2024, October 2024 and November 2024. Based on interviews, C1 requires monitoring 24 hours a day due to behaviors(getting up to ambulate at any time), walking gait and seizures that can occur at anytime. Based on interviews conducted and documents reviewed, the LPA determined the facility identified a need for a higher level of care of for C1, but did not take the necessary steps to fulfill it.

The preponderance of evidence standard has been met. The allegation of staff is retaining a resident that requires a higher level of care is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.