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32 | LIC9099-C (Page 5)
Additional findings included: Mental health instability, medication noncompliance, refusal to eat, deficiencies in basic living skills, paranoia, isolation, grave disability and unemployed. Overall impairment severity was documented as severe. Interdisciplinary treatment plans were developed for inpatient hospitalization. Documentation noted R1’s behaviors represented: Danger to self or others, property destruction, inability to provide/utilize food, clothing, and shelter, and significant deterioration in functioning. Review of R1’s progress notes revealed no documentation that R1’s physician was notified of medication or meal refusals.
LPA reviewed R2’s Progress Notes (06/01/2024 – 09/29/2024), Appraisal Needs and Services (ANS) Plan (02/11/2025), and physician’s reports (01/24/2017 and 02/21/2025). Documentation indicated: Noncompliance with medications, group meetings, medical appointments, and IDT meetings. MARs (07/01/2024 – 10/31/2024) confirmed medication refusals. Physician’s reports since 2017 did not indicate prescribed medications. ANS noted R2 has been a resident since 2017 and previously ran out of medications while at a shelter.
LPA reviewed R3’s Progress Notes (06/02/2024 – 09/30/2024). Records indicated: History of Q30 high alert for drug use. Weekly positive drug tests for BUP, AMP, MDMA, and METH. Physician’s Report (dated 12/30/2023) documented a substance abuse problem and prior drug rehabilitation. Program/Behavior (BIRP) Notes (dated 09/22/2024) indicated R3 observed smoking through sliding door. Declined group meetings with county substance abuse counselor and AA meetings. BIRP note (dated 09/16/24) documented a fire outside R3’s room caused by smoking in an undesignated area; staff reminded R3 of designated smoking locations. R3 transported to CCRMC on 08/14/2024, 08/17/2024, and 09/18/2024 for medical clearance following positive drug tests.
LIC9099-C Continued...
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