Complaint Investigation Report

Staff did not follow reporting requirements:

On 08/15/2024, LPA interviewed Administrator (ADM). ADM stated he/she did not send the incident report to CCL office because he/she already called the CCL office for the incident.

LPA interviewed Licensing and Regulations Manager (S1). S1 stated he/she received the internal incident report. S1 stated the facility ADM called CCL office to report the incident. S1 was unable to provide the date and time when the call was made. S1 stated he/she did not send the incident report to CCL office because the facility already called CCL office for the incident.

LPA interviewed staff S2. S2 stated before the facility staff reported the incident to Administrator (ADM) and ADM sent the incident report to CCL office. S2 stated now the facility staff report the incident to Licensing and Regulations Manager and Licensing and Regulations Manager sends the incident report to CCL office.

LPA checked the the facility incident report log reported to CCL office, the facility did not send incident report in writing to CCL office.

The facility did not send the incident report in writing within 7 days to CCL office.

The Department has investigated the above allegation. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiency is being cited. See LIC9099-D.

Exit interview was conducted with LRM. The report was provided to LRM for signature. A copy of the report was provided to LRM.