Asian American Drug Abuse Program, Inc.

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Published
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Contact Information
Licensee Name
Asian American Drug Abuse Program, Inc.
5825 W. Olympic Boulevard, Los Angeles, CA 90036
Facility Name
Identification Number
190112FN
Reviews & Findings
Dates of Review
June 22 and 23, 2016
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 12020 Health Questionnaire

The above section states, in part, “The health questionnaire, shall be completed for all participants admitted. Programs may use form ADP 10100-A-E for the health questionnaire or may develop their own health questionnaire provided it contains, at a minimum, the information requested in ADP 10100-A-E. The health questionnaire shall be completed and signed prior to the participant’s admission to the program and filed in the participant’s file.”

The applicant was deficient in meeting the above standard because of the following:
* The health questionnaire for client did not contain a staff signature.
* Client did not contain a completed health questionnaire.

2) Section 12030 Communicable Diseases

The above section states, in part, ”All programs shall have a policy that requires participants who show signs of any communicable disease to be cleared medical before services are provided by the program.”

The applicant was deficient in meeting the above standard because there was no “Communicable Diseases” policy to review.

3) Section 12045(a) Drug Screening

The above section states, in part, ”All programs shall have a written policy… the program shall establish procedures that protect against the falsification and/or contamination of any body specimen sample collected for drug screening. ”

The applicant was deficient in meeting the above standard because the drug screening policy did not address procedures that protect against the falsification and/or contamination of any body specimen sample collected for drug screening,

4) Section 12045(b) Drug Screening

The above section states, in part, ”All programs shall have a written policy. Document results of the drug screening in the participant’s files.”

The applicant was deficient in meeting the above standard because client files for participant did not contain drug test results.

5) Section 12050 Referral For Medical or Psychiatric Evaluation and Emergency Services

The above section states, in part, ‘The program shall have written procedures for obtaining medical or psychiatric evaluation and emergency services.”

The applicant was deficient in meeting the above standard because there was no “Referral for Medical or Psychiatric Evaluation and Emergency Services” policy to review.

6) Section 12060 Alcohol and/or Drug Free Environment

The above section states, in part, “a program shall have written policies regarding service delivery after a relapse episode.”

The applicant was deficient in meeting the above standard because the policies and procedures manuals did not contain policies regarding service delivery after a relapse episode.

7) Section 13000(d)(3)(B) Individual and Group Sessions

The above section states, “The counselor/program specialist shall document, by signing their name and putting the date on the following information for participant’s attendance at individual and group sessions . This documentation shall be placed in the participant’s file: (3) Progress toward achieving the participant’s recovery or treatment plan goals; (B) Residential programs shall document each participant’s progress on a weekly basis.”

The applicant was deficient in meeting the above standard because client files reviewed did not contain participant’s progress on a weekly basis.

8) Section 17005 Program Management

The above section states, “Each program shall comply with all applicable local, state and federal laws and regulations. The program shall develop written procedures to ensure that the program is maintained in a clean, safe, sanitary and alcohol and drug-free environment.”

The applicant was deficient in meeting the above standard because of the following:

California Code of Regulations (CCR), Title 9, Chapter 5, Section 10563 -Accountability states, ‘The licensee, whether an individual or other entity, is.accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.”

The applicant was deficient in meeting the above standard because there were no Americans with Disabilities Act compliant referral policies and procedures to review.

Employees did not have current registration or certification in their personnel files required by CCR, Title 9, Chapter 8, Section 13035(f),
CCR.

9) Title 9, Chapter 8, Section 13035(f) Certifying Organizations

The above section state . in part, “By October 1, 2005 or within six (6) months of the date of hire…all non-licensed or non-certified individuals providing-counseling services in an AOD program shall be registered to obtain certification as an AOD counselor by one of the certifying organizations.”

10) Section 17010(e) Program Policies

The above section states, in part, “All program policies and procedures shall be contained in an operation manual… The policies and procedures manual shall contain… (e) Policies and procedures for: (5) Alumni involvement…(20) Maintenance and disposal of participant files.”

The applicant was deficient in meeting the above standard because the policies and procedures manuals did not contain policies for alumni involvement and maintenance and disposal of participant files.

11) Section 17015(b) Participant Files

The above section states, in part, ”At a minimum, each participant file shall contain the following(3) Other Data(A) Medical referrals and clearances.”

The applicant was deficient in meeting the above standard because client files for participant contain a completed medical referrals and clearances.

12) Section 17015(c) Participant Files

The above section states, “All participant files shall be maintained and information released in accordance with Title 42, Code of Federal Regulations, Part 2.”

The applicant was deficient in meeting the above standard because the confidentiality policy did not contain procedures that address participant files be maintained and information released in accordance with Title 42, Code of Federal Regulations, Part 2.

13) Section 17020 Continuous Quality Management

The above section states, in part, “Each program shall maintain written policies and procedures for continuous quality management and shall document in participant file compliance with the procedures.”

The applicant was deficient in meeting above standard because client files for participants did not contain documentation of compliance with the continuous quality management policies and procedures.

14) Section 19005(a)(4)(E) Personnel Policies

The above section states, in part, “The program shall establish and maintain personnel policies that contain information about the following: Employee safety and injuries.

The applicant was deficient in meeting the above standard because the personnel does not contain information regarding employee safety and injuries.

15) Section 19005(b)(5)(6) Personnel Policies

The above section states, in part, “Each personnel file shall contain: (5) Employee evaluations (6) Health records including a health screening report or health questionnaire, and tuberculosis test results”

The applicant was deficient in meeting the above standard because personnel files for employees did not contain or contained an outdated employee evaluation.

16) Section 19005(e) Personnel Policies

The above section states, “The program shall develop and establish written procedures tor access to and confidentiality of personnel records.”

The applicant was deficient in meeting the above standard because the personnel policies and procedures did not contain written procedures for access to and confidentiality of personnel records.

17) Section 19015(a)/(b)(1) Health Screening and Tuberculosis Requirements

The above section states, in part, “All staff and volunteers whose functions require or necessitate contact with participants or food preparation shall complete a health screening report or a health questionnaire. (b) All staff and volunteers whose functions require or necessitate contact with participants or food preparation shall be tested for tuberculosis…renewed annually from the date of the last tuberculosis test.”

The applicant was deficient in meeting the above standard because personnel files for: Employees did not contain a health screening report or health questionnaire.

18) Section 19020(a) Staff Training

The above section states, “The program shall have a written plan that is annually updated; for the training needs of staff. All staff training events shall be documented and maintained as part of the training plan.”

The applicant was deficient in meeting the above standard because personnel files for employees and did not contain documentation of participation in any training program(s).

19) Section 21000 Admission Agreement

The above section states, in part, “The program shall have a written admission agreement. The program shall place the original signed admission agreement in the participant’s file.”

The applicant was deficient in meeting the above standard because client records for participant did not contain the original copy of the admission agreement.

20) Section 22000(a) Participant Rights

The above section state, in part, “Each participant shall have rights that include, but are not limited to, the following (1) The right to confidentiality as provided for in Title 42, Code of Federal Regulations, Part 2 (5) To be informed by the program of the procedures to file a grievance or appeal discharge.

The applicant was deficient in meeting the above standard because the participant rights document did not contain (1) the right to confidentiality as provided for in Title 42, Code of Federal Regulations, Part 2 and (5) to be informed by the program of the procedures to file a grievance or appeal discharge.

21) Section 22000(c) Participant Rights

The above section states, “The provider shall post a copy of the participant rights in a location visible to all participants and the general public.”

The applicant was deficient in meeting the above standard because the participant rights were not posted in a public area.