Complaint Investigation Report

The number of staff in the facility was dictated by the client census to ensure clients’ needs were met. Staffing requirements for the facility was to have at least two 2 full time staff members at the facility during all three shifts. The day shift 8 – 4 p.m., staff consisted of a Licensed Vocational Nurse (LVN), 1 – 2 Counselor(s), 2 - 3 staff members, and 1 - 2 members of the management team. The night shift, 4 p.m. – midnight, staff consisted of an LVN, one counselor, and 1 member of the management team or 1 staff member. The overnight shift, midnight - 8 a.m. staff consisted of at least 2 counselors or 1 LVN and 1 counselor. Interviews with staff denied the allegation and maintained staff coverage consistently exceeded required levels during all shifts. Interviews with clients consistently indicated that facility staff provided what they needed, and none of the clients interviewed voiced any concerns regarding not having enough staff to meet their needs. Specific information of dates/times when insufficient staff was present to meet client needs was not provided. There was insufficient evidence to corroborate this allegation.

It was also alleged that Licensee did not allow clients to participate in changes to their plan of care. Per staff interviews, the protocol was to complete the weekly summary progress notes when service plans were reviewed with clients. The service plans were reviewed weekly on Sundays with clients and the service plans were changed if needed to meet clients’ needs based on dialogues with the clients. The clients and staff initialed/signed the changes on the on the back side of the service plans and checked off the box indicating whether they wanted to make changes to their service plans. Review of service plans for 4 of 9 clients in care indicated all changes to the service plans were documented in the summary progress notes and both the client and staff signed the signature page as required. The details of any specific clients allegedly affected by changes in their care plans without their knowledge were not identified. The specific time period or staff involved in making these changes were also not identified. The Department was unable to obtain credible information corroborating this allegation. Interviews with staff indicated they were not aware of any clinical staff making changes to client service plans without involving the clients.

It was also alleged that Licensee did not report to licensing the possession of illegal drugs that threaten the health and safety of clients. Specific details including the dates/times, or the clients/staff involved of when the licensee did not report to CCL the possession of illegal drugs at the facility were not identified.