complaint·March 24, 2023

Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents. Relevant party indicated that a resident in care was being charged more than the agreed amount listed on their admission agreement. LPA observed resident (R8’s) admission agreement signed 10/27/2022 and invoices itemizing charges from October 2022 to March 2023. LPA observed that charges for level of care services and pre-admission fees were included in R8’s signed admission agreement. LPA observed that invoice for January 2023 showed a charge for $530 for medication services when, according to interviews with staff members S1, S2, and ED, as well as a review of R1’s Physician’s Report for RCFE LIC 602A dated 12/9/2022 (faxed to the facility on 12/13/2022), R8 was not receiving medication services. LPA observed that $530 were credited back to R8 on invoice for February 2023. LPA observed a charge for $4012.50 for “Private Duty Personnel” for R8’s March 2023 invoice. Interview with ED indicated that service was provided due to an incident in which R8 attempted suicide on 1/1/2023. R8’s updated LIC 602A dated 1/10/2023, which was completed during hospital visit following incident that occurred on 1/1/2023, indicated R8 as not exhibiting suicidal/self-abuse behaviors and not experiencing depression. A comment on the last page of R8’s LIC 602A dated 1/10/2023 indicates that R8 had a “suicide attempt by overdose” but also states that R8 “is not acutely a suicidal or homicidal.” Interview with ED indicated that R8 did not agree to private duty personnel services and implementation of services for R8 was decided by facility. Interview with ED indicated that a meeting with R8 and the facility was attempted to address service implementation, but R8 refused to participate in meeting with facility. R8’s admission agreement signed on 10/27/2022 states “If you become a safety risk to yourself or to others during your residency, we have the right in our sole determination to obtain, at your expense, private duty personnel to provide supervision or assistance until you move from the Community or your safety is no longer at risk.” Due to Incident that occurred on 1/1/2023, the facility began providing additional supervision for R8 to ensure their safety. Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, S9, and ED indicated that there have been no incidents witnessed in which the facility charged a resident fees not indicated in their admission agreement. ** Report continued on 9099-C **