Complaint Investigation Report

Allegation: Staff did not follow the client's needs and service plan.

It is alleged that the facility did not meet the client’s needs as outlined in their plan indicating they would assist the client with their therapy and fly them back home. It is alleged the facility would help the client acquire their Real ID. It is alleged that the facility did not provide the client with services from the plan because the therapist quit during their time at the facility.

Based on interviews, four out of four staff denied the allegation. S3 stated the client #1 (C1) was diagnosed with the mental health condition posttraumatic stress disorder (PTSD). S3 stated that C1 attended some sessions, but the last several sessions were refused. S1 stated they were working at the facility around May to June. S1 stated they worked at the facility with C1 and stated they would attempt to meet with the client every week for classes and therapy, but the client would refuse or would not stay the entire session. S1 stated that if any client refused their session, then they would make note of the client refusing to participate in their clinical progress notes. S2 stated they worked with C1 to fly them over to the facility for admission and agreed to send client back home by providing airfare. S2 stated after C1’s discharge to another facility for additional treatment, if they needed a flight home after that stay, S2 would provide a flight back home. S2 said that C1 texted them for help and they offered to purchase a ticket to fly back home, but C1 stated they already purchased their car to be shipped from their home location to where they were at. S2 stated C1 requested reimbursement to cover their car shipment, which S2 never agreed to do. S2 stated if C1 requested a flight back home, they would provide for them. If the flight was to any other location other than home, facility would discuss how that would fit in with discharge plans. All staff stated they did not recall C1 ever requesting a Real ID. S2 and S3 stated that if the client requested the Real ID and it was needed for their flight back home, they would help the client acquire it. Based on interviews, staff followed the client’s needs and service plan for their PTSD needs, facility would provide flight back home if it was requested, and would have provided the Real ID to the client if it was requested.

Based on record review, the admissions agreement dated May 20, 2025, indicated C1 was admitted to the facility on May 20, 2025. The facility discharge summary dated June 26, 2025, indicated the client left the facility on June 25, 2025 at 10:57 AM to another facility. The admission agreement states on page 1, arrangements for transportation to medical, dental, and/or other appointments coordinated in advance, subject to approval by facility staff. If any client makes a request for a fight home or alternate plans, they would need to speak to facility staff about that.