Complaint·April 20, 2021

Per LPA's interview with administration staff (S1), an activity assistant/staff person (S2), on 10/2/20 at approximately 5PM, delivered a letter that was folded, not in a sealed envelope, to R1's responsible party. Per S1, on 10/2/2020 a second letter that was sealed in an envelope was delivered by staff 2 at approximately 6:45PM to R1's responsible party. The letters contained resident information that is considered confidential. LPA was provided a copy of a written statement by S2 regarding the delivery by S2 of two letters to R1's responsible party; Summary of the letter was stating that S2 had delivered two letters to the responsible party on 10/2/20 at separate times, one letter folded and the other letter in a sealed envelope. S2 had stated in the letter that the letters were not opened during the delivery by S2. Per the investigation, the letter that was delivered folded and not in a sealed envelope left the contents of the letter accessible to others, the folded letter provided no safeguard of residents personal/confidential information from possibly being seen/read by others. Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of resident's personal information was not kept confidential, has been substantiated. Due to the substantiation of the allegation, a citation, 87468.1(a)(1), will be cited today-see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Appeal Rights Given. Per record review and interviews, S3 reviewed medical documentation, current care plan, resident incidents, observation of care being provided to R1. S3 stated they took into consideration input from R1's responsible party on 9/28/20 during the assessment of R1. S3 used the worksheet tool, points system on care needs of the resident, and from this an updated care plan is created. Per interview with S1, and records review, the reassessment documents were provided to the responsible party(RP) on 10/2/2020, delivered by staff to the RP in a sealed envelope. Per review of a letter dated 10/2/2020, summary of the letter stated to the RP that to please notify administration staff of any family member and/or health care professional(s) that RP would like included in a care conference being set-up to discuss the new care plan and reassessment documentation with RP. Per S1, they had discussed with RP on 10/5/20 that the care conference would be a time to review and discuss the reassessment and care plan, and that RP could have someone/others there, a family member, Physician of the resident, other health care professional but at that time the RP told S1 that they would provide information at a later date. S1 stated to the LPA that no information was provided by RP to S1 or any other staff person of RP's family member or health care professional RP would like to be included and/or notified of the care conference. Per record reviews, LPA observed a reassessment document, worksheet tool, and the service plan from the reassessment started on 9/28/20, and completed 10/2/20 by S3, an RN. LPA also interviewed reporting party; Reporting party gave conflicting information to the information obtained from other parties during the investigation. RP does not agree with the reassessment that was done, the increased care needs and services, and the increased fees that were noted in documents received on 10/2/2020. Based on LPA's observations, record reviews, interviews with staff, and conflicting information obtained from other related parties, there is insufficient information to prove or disprove the allegation of Resident was not properly reassessed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.