Brown Scapular Program

Photos
Published
0.000
Contact Information
Licensee Name
Canon Human Services Centers, Inc
9705 South Holmes Street, Los Angeles, CA 90002
Facility Name
Identification Number
190099EN
Reviews & Findings
Dates of Review
3/29/2016
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Section 10511(a) Requirement to Post License Class B

The above section states, in part, “The licensee shall: a) Post the license in a conspicuous place in the facility where ff can be seen by anyone entering the facility.”

The provider was deficient in meeting the above regulation because the current license was not posted in an area that was visible by anyone entering the facility.

2) Section 10563 Accountability Class B

The above section states, in part, “The licensee is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.”

The provider was deficient in meeting the above regulation because the following discrepancies were observed:

a. The medication office was not locked.
b. The cabinet used to secure the resident’s medication was not locked.
c. There was a large, plastic bag of left/unused medications were being stored. .
d. Resident was discharged the and his medications were still being the active medication cabinet and there was no supporting documentation indicating.
e. Resident was prescribed to take 1 pill 4 times a day; to take 1 pill every 8 hours for 7 days; and to take 2 every 8 hours for 10 days. Not taking the medication at all and there was no supporting documentation indicating the prescribing physician was contacted to change or discontinue the medication.
f. Resident was prescribed to take 1 pill with food or milk In AM for 30 days. was not taking the medication was no supporting documentation indicating the prescribing physician was contacted to change or discontinue the medication.
g. Two out of five medication control sheets for: were missing the prescription name, strength and quantity, and instructions for use. The two incomplete sheets indicated medication was taken but only contains the resident’s initials – these medications were not accounted for.
h. Resident was prescribed to take 1 pill 3 times per day for 7 days. was not taking the medication as prescribed and there was no supporting documentation indicating the prescribing physician was contacted to change or discontinue the medication.
i. The cabinet where the closed files are kept was not locked.
j. The medication destruction procedures states the left/unused medications will be flushed in the toilet.
k. The medication destruction procedures states a counselor and a witness will sign the medication destruction log.

3) Section 10565(b) Personnel Records Class B

The above section states, in part, “All personnel shall have on file the record of the health screening as specified in Section 10564.”

The provider was deficient in meeting the above regulation because the personnel files for #3, #6, and #7, did not contain their completed health screening report.

4) Section 10565(b) Personnel Records Class B

The above section states, in part, “b) All personnel shall have on file the record of the health screening as specified in Section 10564.

The provider was deficient in meeting the above regulation because the personnel files for their annually updated TB test results.

5) Section 10564(I)(3)(B} Personnel Requirements Class B

The above section states, “The licensee shall maintain personnel records for all staff 3) Personnel records for staff who provide counseling services shall contain: B) A copy of the code of conduct of the registrant’s or certified AOD counselor’s certifying organization pursuant to Section 13060.”

The provider was deficient in meeting the above regulation because the personnel file for #3 did not contain a copy of the code of conduct from the registrant’s or certified counselor’s certifying organization.

6) Section 10568(b}{8) Resident Records Class B

The above section states, in part, “Each record shall contain information including but not limited to 8) Record of any permitted current medication including the name of the person who prescribed the medication and instructions for its use.”

The provider was deficient in meeting the above regulation because the files for resident did not contain information regarding their current medications including the name of the person who prescribed the medication and instructions for its use.

7) Section 10568(c) Resident Records Class B

The above section states, in part, “All information and records obtained from or regarding resident shall be confidential and maintained in conformity with Title 42, Sub chapter A, Parts 2.1 through 2.67-1,Code of Federal Regulations.”

The provider was deficient in meeting the above regulation because the resident files and medication were in unlocked file cabinets.

8) Section 10581(a) Buildings and Grounds Class C

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

The provider was deficient in meeting the above regulation because the following deficiencies were observed:

Room#3
a. The walls were dirty.
b. The floor was dirty/stained/worn. Room#5
c. The walls were dirty
d. The floor was dirty/stained/worn. Room#?
e. The walls were dirty.
f. The floor was dirty/stained/worn.
g. The smoke detector was beeping.
Room#9
h. The walls were dirty
i. The floor was dirty/stained/worn.
j. There were broken dresser drawers.
Room#11
k. The walls were dirty
I. The floor was dirty/stained/worn.
m. There were broken or missing dresser drawers.
n. The hallway wall was damaged,
Room #15
o. The walls were dirty
p. The floor was dirty/stained/worn.
Room #17
q. The walls were dirty
r. The floor was dirty/stained/worn.
Room #12
s. The walls were dirty/unfinished/patched.
t. The floor was dirty/stained/worn.
Room# 10
u. The walls were dirty
v. The floor was dirty/stained/worn/damaged.
w. There were broken tiles on sink.
x.. The paper towel dispenser was very rusty.
Room#8
y. The walls were dirty and had peeling paint.
z. The floor was dirty/stained/worn. There were broken dresser drawers. The cabinet was broken/worn.
Room#6
cc. The walls were dirty
dd. The floor was dirty/stained/worn.
ee. There was a hole in the ceiling.
ff. The sink counter was cracked.

9) Section 10584(e) Buildings and Grounds Class C

The above section states, “e) All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating conditions.

The provider was deficient in meeting the above regulation because the following deficiencies were observed:

Room #3
a. The walls were dirty and worn.
b. The toilet was dirty and stained.
Room #7
c. The walls were dirty and worn.
d. The toilet was dirty and stained.
e. The floor was dirty, stained or worn.
Room #11
f. The walls were dirty and worn.
g. The toilet was dirty and stained.
h. The floor was dirt y, stained or worn.
Room #15
i. The floor was dirty, stained or worn.
Room#17
j. The floor was dirty, stained or worn.
Room#18
k. The floor was dirty., stained or worn.
L The toilet was dirty and stained.
Staff Men’s Restroom
m. The walls were dirty and worn.
n. The toilet was dirty and stained.
o. The floor was dirty, stained or worn.
Staff Women’s Restroom
p. The walls were dirty and worn.
q. The toilet was dirty and stained.
r. The floor was dirty, stained or worn.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 43
Census: 27

TREATMENT CAPACITY:
Approved: 43
Census: 27