Facility Evaluation Report

On 11/7/2024 at 1:57pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding multiple incidents involving resident to resident altercations and restraint use on a client. LPA met with program director Candice Pelletier and explained the purpose of the visit. LPA reviewed incident reports and conducted a brief interview with program director.

Incident #1: On 10/16/2024, facility reported that client1 (C1) was walking past another client (C2) and punched C2 with a closed fist on C2's right shoulder. Another peer (C3) witnessed this event and punched C1 with a closed fist on C1's upper arm. Staff were able to immediately intervene and separate clients involved. Clients were placed in separate classrooms for the rest of the day for supervision and monitoring purposes. Incident was reported to licensing department, ombudsman, local law enforcement, and clients' responsible parties within regulatory time frames. Facility's noted interventions include continued monitoring of all clients involved for increased signs of peer to peer aggression and planning through interdisciplinary team for any additional interventions needed. LPA observed clients at day program to be supervised appropriately during visit and interacting appropriately with each other.

Incident #2: On 10/14/24, facility report that C4 was seated during a structured activity when another peer touched C4's blanket. C4 responded by swinging arms at staff1 with an open palm. Additional staff were called in to assist due to the escalated behavior. C4 pushed S1 to the ground during S1's attempt to block and evade C4. S2 and S3 arrived for additional support. S2 and S3 made several attempts to verbally redirect, block, and evade C4, however, C4 continue to display physical aggression. S2 and S3 then placed C4 in a two-person low-level seated hold for approximately 4 minutes. After the hold, C4 returned to baseline behavior and was assessed for injuries. Medical assistance and first aid was not necessary as a result of this incident as no injuries occurred. LPA reviewed staffing files for S2 and S3 and determined appropriate training for Non-Crisis Intervention (NCI) for restraint holds was current and up to date.