Complaint Investigation Report

NOC shift. Admin stated that even though he is asleep, staff have full access to him should a resident or staff need his assistance. However, there is no requirement in regulation for awake overnight staff for Enhanced Behavior Support Homes. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Complaint alleges Administrator (Admin) is not ensuring adequate staffing to ensure care and supervision. Complainant states that Admin falsely lists himself as working the night shift but does not actually work, leaving the facility out of ratio as required by client’s needs. During investigation, LPAs reviewed clients ratio requirements as identified in their Individual Behavior Support Plans (IBSP). Clients C1 and C2 require a 2:1 staffing ratio and clients C3 and C4 require a 1:1 staffing ratio. LPAs reviewed LIC 500 and found the staffing schedule compliant with required staffing ratios as identified in clients’ respective IBSPs. During investigation, LPA was advised that both Francis and the co-Administrator do put themselves on the schedule as designated leads but sometimes are not actually present at the facility. However, during these times they are both available by phone and both do actually answer the phone. Staff unable to provide LPA with dates of observed absences. Therefore, LPA unable to determine if dates when not present were on dates Admin was designated as lead. Additionally, staff schedule reflects quantity of staff present to fulfill staffing ratios required by respective clients’ Individual Behavior Support Plans (IBSP). So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator and a copy of this report given.