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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1069980-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a lack of staffing at the facility resulted in vulnerable adults (VA1 and VA2) being left in bed for most hours of the day with little activities and engagement; and vulnerable adult (VA3) not receiving necessary supervision for his/her seizure disorder. Date of Incident(s): October 26, 2022; November 3 and 14, 2022; and other dates unknown
Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on November 14, 2022; from documentation at the facility; and through interviews conducted with VA1’s guardian and family member (G1), VA2’s guardian and family member (G2), VA3’s guardian and family member (G3), and a facility supervisory staff person (P1). Information was also provided by two care professionals for VA1 (C1 and C2). An additional staff person (P2) initially responded to this investigator, but did not respond to subsequent attempts to schedule an interview. (Note: At the time of the site visit, this investigator met and attempted to interview VA1-VA3. VA1 did not appear to understand or respond consistently to questions. VA2 did not respond to this investigator at all. VA3 had just experienced a fall, and was visibly upset and appeared unable to participate in an interview at that time.) VA1’s support plan and support plan addendum provided the following information: · In January 1980, VA1 moved into the facility seeking supports and services relating to his/her diagnoses, which included cerebral palsy, scoliosis, and seizure disorder. · VA1 shared staff with his/her housemates and his/her required staffing ratio was 1:4 (one staff person per four individuals). · VA1 had limited vocabulary, and was susceptible to abuse from others. VA1 relied on staff to intervene and/or report suspected abuse on his/her behalf. · VA1 used an electric wheelchair to move around and relied on staff to complete all of his/her activities of daily living, and all medical needs. · According to VA1’s Intensive Support Self-Management Assessment dated August 2022, “[VA1] is able to stand with assistance from staff. [VA1] cannot walk independently, or transfer [him/herself] from [his/her] bed to [his/her] chair. [VA1] is a one person stand pivot transfer.” · The records reviewed for this investigation did not provide specifics regarding what time VA1 preferred to go to bed at night and/or get up in the morning; and there was no documentation in VA1’s progress notes that specified these times either. VA2’s support plan and support plan addendum provided the following information: · In September 1980, VA2 moved into the facility seeking supports and services relating to his/her diagnoses, which included spastic quadriplegic cerebral palsy. · VA2 shared staff with his/her housemates, meaning his/her required staffing ratio was 1:4. · “[VA2] is non-verbal.” VA1 was susceptible to abuse from others. VA2 relied on staff to intervene and/or report suspected abuse on his/her behalf.” · VA2 used an electric wheelchair to move around and relied on staff to complete all of his/her activities of daily living, and all medical needs. · According to VA2’s Emergency Data Form dated January 2022, VA2 used a mechanical lift “as needed” to transfer, and also had a stander that s/he sometimes used. · The records reviewed for this investigation did not provide specifics regarding what time VA2 preferred to go to bed at night and/or get up in the morning. However, VA2’s medication administration records had information about three of his/her medications that were supposed to be administered “at bedtime,” and the scheduled times for these were either 7 p.m. or 8 p.m. VA3’s support plan and support plan addendum provided the following information: · In March 1999, VA3 moved into a different residence that was owned and operated by the same program as the facility. VA3’s diagnoses included epilepsy and recurrent seizures. VA3 relied on staff persons to watch for seizures and activate his/her vagus nerve stimulator to stop a seizure. (Note: Information was provided that prior to January 2022, VA3 was more active and able to move around independently. However, in January 2022, VA3 sustained an ankle fracture and needed in-patient rehabilitative services at a care facility. On August 15, 2022, VA3 was discharged from the care facility. VA3 then moved into the facility, temporarily, while his/her other program residence underwent modifications to accommodate VA3’s increased need for support.) · VA3 was supposed to have 1:1 staffing, 12 hours per day during daytime hours, with the remaining 12 hours per day being shared staffing with his/her housemates, or a 1:4 staffing ratio. VA3 relied on staff to complete all of his/her activities of daily living, and all medical needs. · VA3 was able to communicate verbally, but processed information “slowly” and had a history of memory loss. VA3 comprehended information best visually. VA3 was susceptible to abuse from others. VA3 relied on staff to intervene and/or report suspected abuse on his/her behalf. · According to VA3’s Intensive Support Self-Management Assessment dated August 11, 2022, “[VA3] experiences instability when walking due to the impact on [his/her] balance from [his/her] seizures and head injury and is supported with [his/her] walker, gait belt and staff when needed.” · The records reviewed for this investigation did not provide specifics regarding what time VA3 preferred to go to bed at night and/or get up in the morning. However, VA3’s medication administration records had information about three of his/her medications that were supposed to be administered “at bedtime,” and the scheduled times for these were either 6 p.m. or 7 p.m. The facility was a single-family, one-story home where VA1-VA3 lived together with another housemate (H). Upon entering the facility’s main front door, there was a large open area with a kitchen, and dining and living rooms. All of the bedrooms were clustered together at the end of a short hallway. It was possible to stand in the center of the hallway and see into, or portions of, each bedroom. (Note: There was no information regarding concerns with the H’s overall care and supervision. At the time of the site visit, this investigator met the H and attempted to speak to the H. The H did not respond to or acknowledge this investigator. The H was not interviewed for this investigation.) C1, C2, and G1 provided the following consistent information: · On October 26, 2022, C1, C2, and G1 arrived at the facility for an annual meeting regarding VA1’s supports and services. P2 answered the door but was unaware of the meeting. P2 was the sole staff person at the facility with VA1-VA3, and the H. The time was approximately 1 p.m., and VA1 and VA2 were in bed and there was no information that they had been out of bed at any point prior in the day. · P2 told C1, C2, and G1 that VA1 and VA2 each needed assistance from at least two staff persons to transfer from their respective beds to their respective wheelchairs, and vice versa. The facility had a manual lift; however, this also required two staff persons to use. However, there had been staff turnover and staff on medical leaves, which impacted the staffing levels. As of October 26, 2022, there were four staff total, including P2, who covered the 24/7 shifts at the facility. · C1 said that, at the time of the visit on October 26, 2022, at 1 p.m., VA1 and VA2 looked “happy” in their beds, but also like they had not bathed for “several days.” · C2 described VA1 as “being in need” of grooming, including a haircut. However, the facility, itself, was “very clean and tidy;” and when asked, P2 was able to promptly retrieve VA1’s support plans, medical appointment history, and other documentation. C2 said that it appeared, “[P2] was doing an excellent job with no support.” · G1 said that “recently” the lack of staffing at the facility had been “very distressing.” When asked if VA1 ever raised concerns to G1, G1 explained that VA1 was not able to communicate to that degree; however, “It seems like [VA1] understands more than [s/he’s] able to communicate.” G1 added that besides the lack of staffing, s/he no concerns with the facility’s overall care and supervision; “They’ve been good.” G2 said that “the last couple times” s/he visited VA2 at the facility, VA2 was in bed. G2 typically visited VA2 in early afternoon around 1:20 or 2 p.m.; and VA2 was typically in bed at that time and there were no signs that s/he had been out of bed prior in the day. G2 was concerned that VA2 did not receive frequent baths, and that there were times, G2 worried about how frequently VA2 was offered something to drink. G2 also had received a call from VA2’s doctor that VA2 had missed an unknown number of his/her medically ordered Botox injections. G3 said that VA3 was sometimes able to get out of bed independently and sometimes needed help. G3 previously had concerns about VA3 being left in bed for long periods of time, and believed this was related to a lack of staffing. G3 was also aware that VA3 had missed an unknown number of his/her physical therapy appointments since moving into the facility. On November 14, 2022, at 11 a.m., this investigator visited the facility without prior notification (unannounced). Information had been provided that the facility became aware of the aforementioned concerns, including the need for two staff persons to transfer VA1 and VA2, on November 3, 2022, eleven days prior to this investigator’s visit. At the time of the site visit, the following was observed: · P2 was the sole staff person at the facility with VA1-VA3, and the H. · VA1 and VA2 were in their beds; and VA3 and the H were in their respective bedrooms. All of the bedroom doors were propped open. · Regarding VA1: o Upon entering VA1’s bedroom, s/he was lying in bed, smiling and responsive, and watching television. There were no odors or obvious indications of poor or inadequate hygiene. The room was decorated with pictures and other property that appeared to belong to VA1. o There was a bowl of, what looked like, oatmeal on a table connected to the bed with a spoon nearby. P2 stated that s/he had been feeding VA1 breakfast when this investigator arrived. o This investigator observed VA1 to be lying with his/her body in an “S” shape. VA1’s head was on a pillow in the middle of the mattress with his/her left hip touching a side bed rail and his/her legs bending back towards the middle of the mattress. P2 said that VA1 should be repositioned in his/her bed; however, P2 had previously sustained a wrist injury, which limited his/her ability to do any lifting. P2 said that without another staff person to help, VA1 would have to wait to be repositioned until the next staff person arrived at 2 p.m. P2 said that his/her supervisors were aware of his/her wrist injury. (Note: Although VA1’s position in bed did not look like it would be comfortable to the average person, this investigator had never met VA1 prior and did not know what VA1 typically looked like while lying down.) · Regarding VA2: o Upon entering VA2’s bedroom, s/he was lying in bed, smiling and responsive, and watching a cartoon on the television. There were no odors or obvious indications of poor or inadequate hygiene. The room was decorated with pictures and other property that appeared to belong to VA2. o P2 noticed the cartoon on VA2’s television and questioned why that was on. P2 stated to VA2, “You don’t like [cartoons], do you?” VA2 did not respond. P2 asked VA2 if s/he should turn on the movie, Annie; and VA2’s face lit up with a big smile. P2 told this investigator that VA2 “loved” to watch Annie. P2 then began pushing buttons on the television and eventually came to a still frame from the Annie movie; however, before P2 could figure out how to turn the movie on, this investigator and P2 heard VA3 yelling for help inside his/her bedroom across the hall. (Note: VA2’s television set remained with a still frame from the Annie movie for the remainder of this investigator’s visit.) · Regarding VA3: o P2 ran into VA3’s bedroom followed by this investigator. VA3 was sitting on the floor between his/her bed and recliner. VA3 was visibly upset and physically shaking. P2 sat on the floor next to VA3 and held VA3’s hands in front of him/her. P2 asked questions of VA3 and determined that VA3 had tried to stand up from the recliner to transfer to his/her bed, and had fallen in the process. P2 explained that at times VA3 forgot that s/he needed help to transfer. VA3 was physically uninjured but appeared upset. P2 continued to sit with VA3 and encouraged him/her to breathe. o VA3’s bedroom did not have odors or obvious indications of poor or inadequate hygiene. The room was minimally decorated. It should be noted that immediately upon leaving the site visit, the Department of Human Services contacted the facility administrators regarding the aforementioned observations. The administrators took immediate action by sending additional staff persons to the facility that same day, and also took action as described in the forthcoming paragraphs by P1. P1 provided the following information: · Historically, the facility was staffed with one to two staff persons 24 hours a day for the care and supervision of VA1, VA2, and the H (prior to VA3 moving in). The facility also, historically, had enough staff to cover the shifts and cover various staff leaves without issue. (Note: The facility provided information to this investigator that P2’s typical shift was single-staffed from 7 a.m. to 2:30 p.m. The afternoon shift was typically double-staffed between 2 and 10 p.m.; and the overnight shift was single-staffed between 10 p.m. and 7 a.m.) · VA1 had historically been able to transfer with assistance from one staff person. (Note: As previously stated, VA1’s Intensive Support Self-Management Assessment dated August 2022, three months prior to this investigation, stated that “[VA1] is able to stand with assistance from staff … [VA1] is a one person stand pivot transfer.”) VA2 transferred using the facility’s manual lift, which required two staff persons to use, but this level of staffing had historically been available when needed. The H was able to transfer independently. · On August 15, 2022, VA3 moved in and, after having sustained an ankle fracture, needed an increased level of staffing for mobility; however, since VA3’s mobility changes were relatively new, the level of staffing required for his/her transfers was uncertain or to be determined. VA3 also had a seizure disorder, which required monitoring by staff to intervene if a seizure were to occur. VA3’s support plan specified that s/he would receive 12 hours per day of 1:1 staffing. The facility had additional staffing at this time to accomplish VA3’s staffing needs. · Between August and November 2022, the facility began experiencing a gradual increase in staff turnover. Also during this timeframe, VA1 began experiencing a gradual onset of generalized weakness, and needing increasing support for his/her mobility. · Around the beginning of November 2022, one facility supervisor abruptly resigned, and two other supervisors went out on extended, unplanned leaves. In the supervisors’ absences, P2 took over supervision of the house; an administrator, who typically worked with employment services, was asked to support the house; and another supervisor was asked to fill-in, but ended up having to work direct care due to short-staffing in other homes that s/he already provided support for. As a result of all of these changes, the main concerns regarding staffing “unfolded around the beginning of November (2022).” There were four staff persons, including P2, who continued to work at the facility and fill the 24/7 shifts at the facility. (Note: As previously stated, P2’s typical shift was single-staffed from 7 a.m. to 2:30 p.m. The afternoon shift was typically double-staffed between 2 and 10 p.m.; and the overnight shift was single-staffed between 10 p.m. and 7 a.m.) · Prior to this investigation coming to light, P1 had initially been doing file audits of all of the 42 homes owned by the same company, including the facility. However, P1 had not completed an audit of the facility yet, or by the time of this investigation. · On November 3, 2022, P1 was asked to go to the facility to help with the training of P2, who had recently taken over supervision of the house. Upon arriving, around 10:30 a.m., P1 became aware that the facility, which had been single-staffed during most hours of the day, needed to add staffing in order to meet the housemates’ needs. The housemates were in their beds and unable to get out without additional staffing. P1 ended up helping with direct cares in lieu of training P2. P1 told a supervisory staff person about the “need for more support” at the facility. P1 did not know what follow-up occurred at that point, but believed the situation had been addressed until this investigator’s unannounced site visit revealed ongoing concerns on November 14, 2022. · On November 14, 2022, the facility sent a team of administrators and staff persons to the facility to help. Five staff persons from other programs volunteered to work fulltime at the facility until positions were filled; five administrators and supervisors were supporting the facility in some manner; and additional staff had been hired to work specifically at the facility. (Note: This investigator did not return to the facility after November 14, 2022, to confirm that the staffing was addressed; however, this investigator spoke to P2 on November 30, 2022, regarding setting up an interview, and at that time, P2 told this investigator that s/he was no longer working alone and that there had been additional staff at the house every day since November 14, 2022.) · Facility administrators were meeting frequently to determine how the facility “could fall this far off track … I don’t know how it fell off the radar … We dropped some balls.” · P1 was not aware of any injuries sustained by the housemates as a result of the lack of staffing, but added that the housemates should have been repositioned more frequently and should have gotten out of bed and into the community more than they were. · Since this investigation came to light, P1 and other administrators had been going through all records and immediately addressing concerns as they were uncovered. For instance, it was discovered that VA2 had missed his/her acid reflux medication for an unknown amount of time because it had not been added to his/her medication administration records; this had since been corrected. VA2 had missed an unknown number of his/her medically ordered Botox injections, which had since been corrected. VA3 missed an unknown number of his/her physical therapy appointments, which had since been corrected. VA1’s interdisciplinary team (IDT) was contacted to assess his/her increase in mobility needs and whether this changed VA1’s staffing requirements. The IDTs for VA1 and VA2 were contacted to determine if funding was available to purchase a mechanical lift, in place of the manual lift already present at the facility. The facility’s facsimile machine was offline, which had since been fixed. P1 said, “We are trying to wrap our heads around what was missed.” This investigator reviewed personnel and training records for six staff persons who had worked at the facility prior to November 14, 2022 (site visit date), including P2. Facility documentation stated that these staff persons received training on the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. However, the facility was unable to locate any documentation that these same staff persons received training on VA1’s-VA3’s support plans. This was in violation of Minnesota Statutes section 245D.09, subdivision 5, paragraph (a), clause (2), which states that the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, training, and performance evaluations as required under section 245D.09, subdivisions 3 to 5, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. (Note: P1 said that since this investigation came to light, all staff persons had received additional training, including on the individuals’ support plans.) Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.05, subdivision 1, states that the license holder must meet a person’s health service needs as assigned in the person’s support plan and support plan addendum, consistent with the person’s health needs. Minnesota Statutes section 245D.05, subdivision 2, paragraph (b), states that if responsibility for meeting the person's health service needs has been assigned to the license holder in the support plan or the support plan addendum, the license holder must implement medication administration procedures to ensure a person takes medications and treatments as prescribed Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states that the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum, and in compliance with the requirements of this chapter. Conclusion: A. Maltreatment: Information was provided by C1, C2, G1, G2, and P1 that on October 26 and November 3, 2022, and other unknown dates, the facility’s staffing ratio, including one staff between 10 p.m. and 2 p.m., and two staff the remaining hours, no longer met the housemates’ needs. Around that time, VA1 and VA2 each required two staff persons to transfer out of bed and/or back into bed. This meant that if either wanted to be out of bed in the morning, they would have to get out of bed around 7 a.m., when the overnight shift overlapped with the morning shift. The individual would then have to remain out of bed until the next time there were two staff working, starting at 2 p.m. For this reason, when VA1 and/or VA2 were observed in bed by C1, C2, and G1 at 1 p.m. on October 26, 2022; by G2 at 1:20 or 2 p.m. exact dates unknown; by P1 at 10:30 a.m. on November 3, 2022; and by this investigator at 11 a.m. on November 14, 2022, it was reasonable to believe that they had not been out of bed since at least 10 p.m. the day prior. G3 also had concerns that VA3 was left in bed for periods of time, and that s/he at times needed assistance to transfer out of bed. During the facility’s internal investigation, they discovered additional concerns, including a medication that was not administered, which was in violation of Minnesota Statutes section 245D.05, subdivision 2, paragraph (b); appointments that were not attended, which was in violation of Minnesota Statutes section 245D.05, subdivision 1; and 1:1 staffing requirements that were not met, which was in violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). Although there was no information of injuries to VA1-VA3, and the overall hygiene cares appeared adequate (the individuals, their bedrooms, and the overall facility was “clean and tidy” and without odors); VA1-VA3 relied on staff persons to transfer out of and into bed, and to provide some sort of engagement throughout the day. This was not provided for an unknown number of days, between at least October 26 and November 14, 2022. In addition, the facility initially became aware of these concerns on November 3, 2022, but the concerns remained present when this investigator visited the facility eleven days later. Although the exact impact on VA1-VA3 was unknown given their limited communication skills, it was reasonable to expect that being left in bed or being left without adequate engagement would be considered by a reasonable person to be disparaging, derogatory, and humiliating. Therefore, there was a preponderance of the evidence that VA1-VA3 were subjected to conduct, which was not an accident or therapeutic conduct, and could reasonably be expected to produce emotional distress. It was determined that emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). In addition, given the reliance on staff persons for most activities of daily living, including the act of getting out of bed in the morning and/or repositioning, and that this was not consistently provided, there was a preponderance of the evidence that there was a lack of services and supports provided to VA1-VA3, which were reasonable and necessary to maintain their mental health considering the physical and mental capacity or dysfunction of VA1, VA2, and VA3. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Given that the facility was responsible for hiring and training staff persons and ensuring required staffing that met the individuals’ needs was maintained; and that the facility had been made aware that staffing levels did not meet the individuals’ needs =on November 3, 2022, but did not take action to address these concerns until this investigator’s site visit, the individual staff persons’ responsibilities were mitigated. The facility was responsible for emotional abuse and neglect of the VA1-VA3. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated emotional abuse and neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because there was no information that VA1, VA2, and/or VA3 sustained a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought. The substantiated emotional abuse and neglect of VA1-VA3 was also considered a single incident for each because the incidents for each met two definitions of maltreatment. Action Taken by Facility: The facility completed internal reviews regarding the overall care and supervision of VA1, VA2, and VA3. The facility determined that the support plans and support plan addendums, and policies and procedures, were adequate, but not followed. “Adequate staffing patterns were not being maintained to support [the housemates’] needs due to staffing issues and leadership vacancies.” The facility provided additional training to all direct support staff persons; and training “for leadership on hiring, scheduling, and maintaining adequate staffing.” Additional staff persons were hired to work at the facility, including additional leadership. Action Taken by Department of Human Services, Office of Inspector General: On February 22, 2023, the license holder was ordered to forfeit a fine of $3000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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