Facility Evaluation Report

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent Case Management – Incident visit today for the purpose to continue the investigation of a self reported incident report. Upon arrival, LPA met with Leah Kolbeck and explained the reason for the visit.

On 01/08/2025, Client #1 (C1) arrived at the program at 09:00 a.m. C1 was not provided incontinent services until 01:30 p.m. C1's garment was observed to be wet and was allegedly sitting in wet garments since approx 09:00 a.m. C1 also arrived with the incorrect water. C1 is to have thickened water at 08 oz, but C1 arrived with 6 oz of water and it was not thickened. Staff informed the nurse at 01:00 p.m. to correct the water. On 01/23/2024, between 09:00 a.m. - 01:15 p.m, the initial Case Management - Incident visit was conducted in conjunction with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel. During the visit LPA and QAS interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. Today LPA interviewed staff and reviewed additional pertinent documentation relevant to the investigation. Interviews conducted with ten (10) staff members indicated that nine (9) of the staff have never observed C1, or any client, to be visibly soiled for an extended period of time. One (1) staff member reported observing C1 visibly soiled on one occasion, at which point they immediately notified other staff and C1 was promptly changed. All staff members confirmed that if any client is observed to be visibly soiled, they are promptly changed. Interviews with the ten (10) staff members also revealed that none of them have ever observed any client going without food or drink for an extended period of time. Records review of C1's file revealed they are to have 4 OZ of water (nectar thickness) after every meal. On 01/08/2025, staff informed the nurse at approx 12:45 p.m. that the water needed additional thickener. Based on the investigation, there is insufficient evidence to suggest that C1 was not changed in a timely manner or that C1 was not provided with water in a timely manner due to a lack of care or supervision.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.