Complaint Investigation Report

During the initial complaint visit, LPA Balisi obtained copies of documents found in the staff files and during the subsequent visit, LPA Dulek reviewed staff files. Of 4 (four) staff files reviewed, all were missing documentation to verify staff training, 1 (one) was missing a health screening and tuberculosis test results, 1 (one) was missing a personnel report/resume, and 2 (two) were missing a criminal record statement. Staff interviewed stated that training had been provided, but documentation was not signed off and filed appropriately to date. Documents obtained during the initial complaint visit included training hours from 2022 for 1 (one) staff. There were no copies of the aforementioned documents identified as missing during the 12/04/2024 file review collected during the initial visit. Interview with Administrator revealed that the Administrator maintains all employee files, and on occasion receives assistance with auditing employee files.

During the subsequent complaint visit, LPA Dulek reviewed 4 (four) client files. Of the 4 (four) files reviewed, LPA observed the following: Medical assessments for all 4 (four) clients were dated between 2020 and 2022, needs and service plans for all 4 (four) clients were dated between 2019-2021, and only 1 (one) client file contained a mental health intake assessment.

According to staff interviewed, Client #1 (C1), who was mentioned in the complaint, has not had a medical exam in some time. Staff stated that C1 typically leaves the facility early in the morning and does not return until 5:00PM or later most days. Even when staff have reminded C1 that they have a medical appointment, C1 leaves the facility and misses the appointment. As a result of C1 not attending scheduled medical appointments, the facility was unable to obtain C1’s medications from the pharmacy at the time of the complaint. Facility staff contacted C1’s medical provider, who indicated they were unable to refill C1’s medications until C1 was seen by their medical provider. C1’s medical provider informed facility staff that they are able to take C1 to the urgent care associated with the medical practice after hours, which would fulfill the requirement of seeing the medical provider and therefore, C1’s medications could be refilled. However, at the time of the subsequent visit, facility staff had not taken C1 to the urgent care or to a regularly scheduled medical appointment. C1’s file did not contain any documentation related to notifying C1’s responsible person of the missed medical appointments nor any documentation of scheduled appointments with C1’s medical provider. Facility employees interviewed acknowledged C1 was missing medications for some time due to C1 not attending medical appointments.