Community Service Organization, Behavioral Health Programs

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Contact Information
Licensee Name
Community Service Organization, Behavioral Health Programs
1124 Baker Street, Bakersfield, CA 93305
Facility Name
Identification Number
1500118N
Reviews & Findings
Dates of Review
20-Oct-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 13015(f) Certifying Organizations

The above section states, in part, “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 specified in this regulation.”

The provider was deficient in meeting this standard because a current counselor registration was not contained in the personnel file for employee 1.

2) Section 12020 Health Questionnaire

The above section states, in part, “The health questionnaire, shall be completed for all participants admitted for residential or nonresidential alcohol and/or other drug services.”

The provider was deficient in meeting this standard because a health questionnaire was not completed for participants 1 and 2.

3) 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 failed to meet this standard because a written procedure for obtaining medical or psychiatric evaluation and emergency services was not available for review during the site visit.

4) Section 12055 Referral Arrangements

The above section states, in part, “Program policies and procedures shall identify the conditions under which referrals are made.”

The applicant failed to meet this standard because policies and procedures for which referrals are made were not available for review during the site visit.

5) Section 19005(b) Personnel Policies

The above section states, in part, “The program shall maintain personnel files on all employees. Each personnel file shall contain: (3) Job description; (4) Salary schedule and salary adjustment information; (6) Health records including a health screening report or health questionnaire.”

The provider was deficient in meeting this standard because the following documents were not contained in the personnel files:
• Job description for employee 4
• Salary schedule for employee 4 and 6
• Health records for employees 1, 2, 3, and 6

6) Section 19015(b)(1) Health Screening and Tuberculosis Requirements

The above section states, “All staff and volunteers whose functions require or necessitate contact with participants or food preparation shall be tested for tuberculosis. The tuberculosis test shall be conducted under licensed medical supervision not more than three months prior to or seven days after employment and renewed annually from the date of the last tuberculosis test.”

The provider was deficient in meeting this standard because updated tuberculosis test results were not contained in the personnel files for employees.

7) 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 provider was deficient in meeting this standard because ongoing training was not documented for Employee.

8) Section 26010(a)(4) Health and Safety

The above section states, “Programs shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of participants, employees and visitors.”

The provider was deficient in meeting this standard because of the following conditions: Damaged tile floor throughout main group room and issing bulbs in back group room.