Complaint Investigation Report

(PAGE 2) Report continued from LIC 9099...

During today’s visit, starting at 10:33 a.m. LPA and staff conducted a physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations, at 10:50 a.m. conducted an in-person interview with the Administrator, at 11:00 conducted a file review, and obtained copies of pertinent documents relevant to the investigation.

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 Client #1(C1) did not contain documented evidence of ongoing review of progress towards reaching established goals, was not completed at least weekly, the treatment/ rehabilitation plan for C1 and Client #2 (C2) did not contain documented evidence of methods to evaluate achievement of goals, and the discharge summary for Client #3 (C3) did not contain documented evidence of an outline of goals accomplished and referral follow-up plans. 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 05/14/2025. File review revealed that on 05/14/2025 the treatment/ rehabilitation plan for C1 did not contain documented evidence of ongoing review of progress towards reaching established goals. The treatment plan (TP) in C1’s charts did not have updates. There was only one TP. The TP needs to be current and accurate signed by both staff and client. There was only one TP for Client #1 who arrived 4/28/25 and had the initial TP done on 4/29/25 but no updates after that date. The treatment/ rehabilitation plan for C1 and C2 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. The discharge summary for C3 did not contain documented evidence of an outline of goals accomplished and referral follow-up plans. Portions were left blank for referral and follow up information which poses/posed a potential health, safety or personal rights risk to persons in care. On todays visit the TP for C1 was updated with a weekly review of what was done the previous week and is current. TP for C1 and C2 contained updated documented evidence of methods to evaluate achievement of goals. TP for C3 contained documented evidence of an outline of goals accomplished and referral follow-up plans. 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.