Complaint Investigation Report

They rendered their services on a monthly or as needed basis. Previous invoices reviewed confirmed ongoing services from November 2021 – February 2022. Recent invoices dated April 2022 – July 2022 confirmed that the facility continues to use the pest control company on a monthly basis to prevent bed bugs and cockroaches. Interview with an outside source stated that a client (C1) had a bed bug when client left the hospital. Interview with staff revealed that clients, including C1, are able to leave the facility premises unassisted throughout the day. Per staff interview, clients have previously contracted bed bugs while out in the community, which is one reason that the facility ensures ongoing pest control services. Per staff, they also clean client beds with an insecticide used to control hard-to-kill pests such as bed bugs. On July 26, 2022, LPA toured the facility and inspected C1’s shared bedroom. LPA observed that the client’s bed had a plastic cover over the mattress. When the mattress cover was unzipped, LPA observed that the mattress was free from bed bugs and did not observe bed bugs or eggs on the mattress. LPA looked under the bed board and in the creases of the wall and the floor. LPA took photos which confirmed that the shared room did not have any evidence of bed bugs.

It was also alleged that July 17, 2022, the facility did not answer the telephone promptly which resulted in a client not being able to discharge from the hospital in a timely manner. Interview with an outside source stated that they made contact with staff who made arrangements to have medical transport drop the C1 off, who was discharged from the hospital back to the facility. When medical transport arrived to leave the client at around 10:51 PM (2251 hours), they were unable to enter the facility. Outside source said that the facility was “locked” and they were not able to leave the client at a locked facility. Outside sources attempted to contact staff multiple times to no avail. Medical transport returned the client to the hospital until they were able to contact staff again the following day on July 18, 2022, at around 7:00 AM. Interview with staff said that the facility answers phone calls but at times when the clients are using the phone, calls will go to voice mail. The staff mentioned that it is difficult to answer calls between 5:00 PM – 6:00 PM during dinner time and calls between 8:00 PM – 10:00 PM during distribution of night medications and snack time. Calls during said times are sent to voicemail since there is limited staff during the night shift to answer calls and attend to clients. Per staff, calls are returned within a 24-hour timeframe.