Complaint Investigation Report

Staff additionally informed that C1's behaviors exceeded the resources of the facility and that C1 required a higher level of care than the facility could provide. During the investigation staff confirmed that a higher needs facility placement was secured for C1. Staff consistently stated that the training was sufficient for the clientele the facility served.

LPA was unable to interview C1 during the facility visits. During unannounced facility visit on 04/17/2025, C1 presented with two significant behavior episodes resulting in staff initiating C1's behavior protocol plan twice. LPA observed C1 push past the delayed egress without staff supervision during both episodes and refuse to return back to the home. During one of these events C1 entered the facility van, locked themselves in from the inside, and attempted to break a window with a flashlight. LPA made a second unannounced facility visit to attempt to speak to C1, however C1 no longer lived in the home, having been relocated to a facility that offered a higher level of care. Interview with additional clients revealed no concerns regarding staff training or elopement protocols.

Two outside sources were interviewed regarding the allegation. An outside source from a protective agency familiar with the facility (OS1) expressed concerns regarding the number of elopement emergencies the facility was having for C1 and believed staff needed more training to prevent inadvertently exacerbating C1's behaviors. A second outside source from a placement agency familiar with the facility (OS2) stated that they had no concerns regarding staff training, and that the facility went above and beyond to meet the needs of C1. OS2 additionally stated that C1's behaviors exceeded the type of care and intervention the facility could provide, and that C1 required a higher level of care.

Records review showed that staff was given training to meet the needs of clients that the facility is licensed to serve. Records additionally also showed that C1's behaviors were greater than the level of care that the facility was able to provide, and that the facility took action to assist in finding C1 a placement that could handle C1's higher care needs.

LPA Patterson directly observed two behavior incidents with C1 during an unannounced facility visit on 04/17/2025. Both incidents resulted in C1 advancing past the delayed egress and into the driveway. LPA observed staff conduct consistent elopement procedures by notifying staff over the walkie, positioning themselves within required ratio to observe C1 from a distance, and attempting to de-escalate.