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25 | Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit at approx 09:10 a.m. for the purpose of investigating a self-reported incident report. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel. Upon arrival, LPA and QAS met with Program Supervisor Tara Gilbert 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.
LPA and QAS conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation.
No immediate health and safety concerns were observed during the visit. LPA has determined further investigation is needed and will return at a later date to continue.
Exit interview conducted. A copy of the report was issued. |