Complaint Investigation Report

On the allegation – Staff violated clients personal rights.

It was alleged that on 04/03/2025, a client (C1) had personal property (a guitar) taken away by lead staff. It was also alleged that staff threatened to remove C1 from the facility. Additionally, it was alleged that the facility withholds clients’ cigarettes and access to outings as a form of behavioral control, only allowing access if clients complete assigned daily tasks.

Interviews with the LS 1, facility staff, and outside supports for C1 revealed that the guitar in question was provided by an outside clinician and intended to be given to C1 upon discharge. However, the LS 1 gave the guitar to C1 in error on the morning of 04/03/2025. Upon realizing the mistake, the LS 1 retrieved the guitar. When C1 later requested the guitar, the LS 1 refused, which led to an escalation in behavior and raised voices from C1 and LS 1. The LS 1 reported feeling unsafe during the interaction.

LPA reviewed C1’s personal property inventory, which listed the guitar as belonging to C1. Additionally, C1’s intake documentation noted that playing music is a calming strategy for them when upset.

Interviews with lead and support staff confirmed that clients’ cigarettes are stored in the staff office and distributed during designated “outside break times.” Staff also acknowledged that access to cigarettes and outings is sometimes contingent upon clients completing daily expectations, such as attending groups.

Documents collected during the investigation included:

A calendared schedule of events with a notation on the bottom of the calendar stating: “Outside breaktime only if client attended previous group and arrived on time.” And stating: “Community time from 2–4 p.m. if client attended all groups on time the previous day.” A document titled “Agnes CRT FRESH AIR/Smoke Break SCHEDULE” listing ten 15-minute breaks and one 2-hour break. A staff communication dated 01/29/2025 stating: “Effective immediately, clients must keep their cigarettes in the hub… they need to turn them into us when they purchase new ones.” An additional communication from the administrator dated 2/1/25 stating: “…remind them if they continue to share… they will have their smoke breaks revoked for the entire day, no exceptions.”

Based on interviews and documentation reviewed, the preponderance of evidence supports the allegation that C1’s personal property was withheld. Additionally, facility practices regarding access to cigarettes and outings appear to be used as behavioral incentives, which may restrict client rights. Therefore, the allegation is SUBSTANTIATED.