Regarding the allegation staff does not prevent clients from engaging in physical altercations with other clients, an interview with an Outside Source #1 (OS1), who is familiar with the facility and clients in care, reported not having concerns regarding staff not preventing physical altercations between clients. OS1 reported that Client #1 (C1) is known to make false accusations about being hit. An additional Outside Source #2 (OS2) also reported C1 is known to report being physically attacked when it did not happen.

Regarding the allegation that staff do not ensure reporting requirements are followed, records reviewed revealed Incident Reports from the facility being submitted to the Department which indicated all appropriate parties and agencies being notified. Further, an interview with OS1 who also requires Incident Reports be submitted, stated not having any reason to believe the facility does not follow reporting requirements. OS1 reported staff do appear to be submitting reports when needed.

Regarding the allegation staff does not ensure C1 is provided transportation to attend religious services, in an interview C1 did not report to LPA wanting to attend any religious services. Interviews with facility staff reported that C1 will sometimes request watching religious services on tv and staff ensures these requests are honored. OS1 did not report any concerns regarding facility staff preventing clients in care from engaging in religious practices.

Regarding the allegation that staff does not ensure direct supervision is provided to clients at all times, an interview with OS1 reported not having concerns regarding lack of supervision for clients. OS1 reported the staff to client ratio for the designated level of this facility has always been met. Additionally, during unannounced facility visits LPA observed adequate staff providing direct supervision to clients.

Regarding the allegation that staff does not ensure client is provided personal privacy during phone conversations, interviews with clients reported feeling that they are able to take phone calls wherever they want in the facility. An interview with OS1 did not report any concerns regarding clients not being granted privacy for phone calls.

(Continued on LIC9099C)

Regarding the allegation that licensee does not ensure facility is financially stable, specifically in order to maintain the facility telephone, during unannounced visits to the facility LPA observed the facility phone to be in working order. Interviews with clients reported the facility phone working when they need it. The administrator presented LPA proof of maintaining the phone bill.

The Department has investigated the above mentioned allegations and based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated.

An exit interview was conducted with Administrator Katrina Russell, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.