Complaint Investigation Report

On the allegation, "Facility did not keep current and accurate records"; it is the concern of the Reporting Party (RP) that the treatment/rehabilitation plan for Clients #1 (C1) and #2 (C2) did not contain documented evidence of ongoing review of progress towards reaching established goals., did not contain documented evidence of methods to evaluate achievement of goals and the treatment/rehabilitation plan reviews for C1 and C2 were not signed by staff for each update review and were not completed at least weekly. Furthermore, it was reported that the discharge summary for Client #3 (C3) did not contain documented evidence of reason and plan for discharge.

To investigate this complaint, LPA conducted a file review for C1, C2, and C3, and reviewed the California Department of Health Care Services (DHCS) annual review dated 05/29/2025. File review revealed that on 05/29/2025 the treatment/ rehabilitation plans for C1 and C2 did not contain documented evidence of ongoing review of progress towards reaching established goals as there is no clear update about what was done the past week in the Treatment Plans (TPs), the comment sections were very brief and limited; the TPs did not contain documented evidence of methods to evaluate achievement of goals. The objective or plan was not measurable with a method to evaluate the goals. For example, in C2’s TP it states the objective is to “learn new alternative ways to recognize and manage anger”. And the Plan is “Client will learn body signs of anger and will use the body scale daily.” To make this measurable they should say client will identify three alternative ways to recognize and manage anger. Or Client will learn three body signs of anger and will use the body scaled daily to reduce anger from a 10 on the scale to a 5 over the next seven days. In addition, TP reviews must be done at least every 7 days and signed by both staff and client; TPs for C1 and C2 were done on 5/19/25 and then not updated until 5/27/25 (8 days) and only signed by the clients and not staff. Furthermore, C3 was missing information for where the client was being discharged to. During today’s visit all TP plans for C1, C2, and C3 remained the same. Based on information obtained, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Facility did not keep current and accurate records is deemed Substantiated at this time.

Report will continue on LIC 9099-C, 3rd page.