Complaint Investigation Report

One client reported that S1 will take away smoke breaks for all clients if the smoking rules are not followed. This client feels that this is understandable because they believe rules are important and should be followed and will often tell staff when clients don’t follow the smoking rules, even though it means they will lose their smoke break. Other clients interviewed thought this rule was unfair and that only the client who breaks the rules should get their smoke break taken away. Interview with Staff 1 (S1) revealed that the previous administration made this rule and viewed smoking as an “earned privilege” and S1 didn’t like enforcing it, and didn’t feel it was fair. They admitted it was not fair to take away other’s smoke breaks and wasn’t aware they weren’t supposed to enforce it and agreed to stop enforcing it.

Clients interviewed were under the impression that if they didn’t complete their chores, perform their hygiene routine, or go to groups then they would not be able to go on their 2-4 break out into the community. Clients interviewed didn’t have a problem with this guideline and understood that this was a rehab program to get better and doing chores, ADLs, and attending group is a part of that. Staff interviewed stated that they don’t really enforce these guidelines and they know chores and groups aren’t mandatory. Staff stated they try to meet clients where they are at but incorporate these activities of daily living and the Community Pass Policy in order to build independent living skills.

Staff and Clients revealed that the policy for drug testing is a change in behavior. Clients stated they know they could be drug tested at any time. A few clients interviewed stated they had recently been drug tested and didn’t think it was unfair or for no reason. One client stated they have told staff on several occasions that certain clients should be tested based on their behavior. Staff interviewed revealed they will test clients if they come back from the 2pm-4pm community time acting or behaving strange or different and possibly be under the influence. One staff interviewed stated C1 was tested multiple times due to strange behavior. Staff mentioned one day C1 moved all the furniture around so they tested C1 for possible substances and it wasn’t without reason or to single C1 out.

Management stated they counseled S1 multiple times on the correct way to speak to and treat clients. They stated S1 struggled with manic clients that didn’t calm down easily and were very symptomatic. Management indicated S1 liked to nitpick and be punitive, and give “consequences” for not following the rules. Management stated S1 admitted to threaten to call the cops on multiple occasions and would belittle clients. Staff 1 was put on administrative leave on 4/19/23 based on the facility’s internal investigation and stated the allegations were found to be substantiated. Continued on 9099-C