Quality Assurance Report For December, 2011 Submitted by Shirley Jabbi OPWDD Follow-up Incidents for November 2011

Type of Incident: Psychological Abuse (Crowley) On 11/2/2011 Skill Builder II BM heard a loud bang while she was in the med room. She went upstairs to investigate and when she got to the consumers door, she heard staff TP yelling at consumer SB saying dont hit me again. When BM (Skill Builder) arrived at the room SB (consumer) was sitting on the bed crying. Status of the Incident: The allegation was confirmed as TP admitted that he yelled at the consumer and that he took items out of her room as a tactic to get her to conform to the request of bringing her clothes down to get ironed. Although a confirmed determination was made based on the target admitting that, SB was upset that he removed items from her room and that he yelled at SB for hitting This incident was closed at the 11/30/11 IRC meeting and the following recommendations were completed. TP staff returned to work / placed on six months probation, weekly supervision, a written counseling regarding entering a consumers room of the opposite sex, training around behavioral plans, Conflict resolution, training for BM (skill builder II) around appropriate interactions between supervisor and supervisee, and continued counseling for SB around completion of household chores and physical aggression. OPWDD Allegations of Abuse for December 2011 0Crowley Residence 1220th street Residence 0Hughes Residence 0Bright Harp Residence 0Vyse Residence Type of Incident: Allegation of Mistreatment (220th Street) On 12/20/11, Skill Builder II (ME) assisted consumer NA at the LIJ Hospital ACU (plastic surgery) to repair her right ear lobe under general anesthesia. It was discovered that ME rescheduled NA procedure without notifying the RN for directives, or the manager about her action. Corrective Measures Taken: ME was suspended pending the outcome of the investigation. Consumer NA was reassured that her procedure would be completed on 1/3/11.

Determination: The allegation of mistreatment was found inconclusive. There was not sufficient evidence to conclude that the appointment was rescheduled by ME. Both ME and NA reported that the appointment was rescheduled by the doctor due to over crowdedness. Even though NA reported on 12/20/11 that ME rescheduled the appointment, when the investigator spoke to NA she reported that the appointment was rescheduled by the doctor. NA might have been disappointed as this appointment was scheduled in September and she looked forward to having her earlobe repaired as she takes pride in her appearance. GG reported that ME stated the appointment was rescheduled by the doctor. On 12/21/11 DM (Residence Manager) attempted to speak to staff at LIJ in the surgery outpatient department and she was unable to gather any information regarding why the appointment was rescheduled or if ME rescheduled the appointment. ME did report that she did not make appropriate notifications to the RN even though she did report to GG (Skill Builder II) and DM (Residence Manager). GG did inform the RN of the rescheduled appointment. ME was under the impression that GG made the notifications as she had spoken to him. ME is aware of protocols involving notifications. Recommendations: Reinstate ME to job duties A written counseling for ME for failing to write the outcome in the medical log, and not following the supervisors directives. Verbal counseling for not taking the agency phone to the appointment, and not following procedure in regards to not calling the nurse to inform, her that the appointment was rescheduled. Retraining in protocols and procedures regarding medical appointments This incident is opened pending further recommendations at the January 2012 IRC meeting. OFFICE OF MENTAL HEALTH FOLLOW-UP INCIDENT FOR NOVEMBER 2011 Type of Incident: Sexual Assault (Hunter Apartments) PN reported to the police that on 10/28/11 around 6:00PM that she was raped and assaulted by GJ. Status of the Incident: The rape and assault charges were disconfirmed by Detective Phelm and Lincoln Hospital. Both consumers have managed to coexist in the facility without any verbal or physical altercations. All recommendations were met and incident closed. This case was closed in the November IRC meeting.

Type of Incident: Missing Person (Haven Apartments) On 11/1/11 consumer ST received her social security check and left Haven Facility. Status of Incident: The police was called and arrived on 11/4/11. Officers conducted a search, staff called local hospitals, correctional facilities and she was not located. The police informed the case manager that the case will be transferred to the missing person department. On 11/8/11 the resident returned to Haven. Casemanager did toxicology, counseled the resident on house rules and to call program when she will not be returning. On 11/11/11 case manager met with resident to inform her that the toxicology results were positive for heroine and cocaine. She was referred to a 28-day program and escorted by the driver on 11/12/11. She returned on 11/24/11 stating that she had a fight with another resident trying to steal her coat. She was asked to leave after the fight. Case manger met with resident and referred her to the Real Center for treating substance abusers. Resident was in agreement with attending the program. This case was closed in the December IRC meeting. Resident is no longer missing. Type of Incident: Allegation of Psychological Abuse (Haven Apartments) On 11/23/11 resident CL spoke to clinical supervisor AP and reported that he felt disrespected by the Case Mmanager LG.CL stated that LG spoke loudly to him and stated he needed to comply with program rules and staff requests. CL admitted to yelling at Case mManager LG. The argument continued and LG told him then pay your rent then. CL reported that he was humiliated because people could hear what casemanager LG said. Recommendations: Conflict Resolution between casemanger (LG) and resident(CL) LG return to work Refer Case Mmanager for disciplinary action for breaking residents confidentiality. Supervisor to address confidentiality of clients with LG Supervisor to discuss with LG appropriate intervention techniques that could have changed the outcome of the incident. This case is open pending the completion of the recommendations. OMH NEW SERIOUS INCIDENTS FOR DEC EMBER 2011 2---Haven 0---Hunter 0---Supported Housing

Type of Incident: Missing Person (Haven Apartments) On 12/14/11 at approximately 10:00pm, the receptionist JB called to inform the clinical supervisor(AP) that client TD was missing 48 hours. Action Taken: A search was initiated by contacting corrections, relatives and hospitals. This incident is open pending locating the resident and discussion at the January 2012 IRC meeting.

HASA SERIOUS REPORTABLE INCIDENTS 0---The Crown Residence 0---Jose Gonzalez Residence 0---Scatter Site 0---CCP Internal Audits: The Crown CCP Scatter Site Queens Trainings: HIPPA trainings will begin in February 2012.