Casa Aurora

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Published
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Contact Information
Licensee Name
Mental Health Systems, Inc.
1932 Jessie Street, Bakersfield, CA 93305-4114
Facility Name
Identification Number
150060CN
Reviews & Findings
Dates of Review
20-Apr-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 12015(a) Intake

The above section states, in part, “If a participant is appropriate for treatment, the following information shall
be gathered 1. Social, economic and family history; 2. Education; 3. Employment history; 4. Criminal history, legal status; 5. Medical history; 7. Previous treatment.”

The provider was deficient in meeting this standard because the following were not contained in the participant files:
• Social, economic and family history for participants
• Education, employment history, and medical history for participant
• Criminal history, legal status for all participants
• Previous treatment for all participants

2) Section 12020 Health Questionnaire

The above section states, in part ‘T he health questionnaire is a participant’s self-assessment of his/her current health status. 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 provider was deficient in meeting this standard because participant file did not contain a health questionnaire.

3) Section 12045 Drug Screening

The above section states, in part, “The program shall document results of the drug screening in the participant’s files.”

The provider was deficient in meeting this standard because drug screenings were not contained in any participant files.

4) Section 12050 Referral for Medical or Psychiatric Evaluation and Emergency Services

The above section states, in part, “The program shall have readily available the name, address, and telephone number of the fire department, a crisis center, local law enforcement, and a paramedical unit or ambulance service.”

The provider was deficient in meeting this standard because these services were not posted or provided in any participant files.

5) Section 12055 Referral Arrangements

The above section states, in part, “The program shall maintain and make available to participants a current list of resources within the community that offer services that are not provided within the program. At a minimum, the list of resources shall include medical, dental, mental health, public health, social services and where to apply for the determination of eligibility for State, federal, or county entitlement programs.”

The provider was deficient in meeting this standard because these services were not made readily available.

6) Section 12070(a) Recovery or Treatment Planning

The above section states, in part, “The recovery or treatment plan shall include the following:
* Statement of objectives to be reached that address each problem; 3. Action steps taken by program and/or participants to accomplish the identified objectives;
* Target date(s) for accomplishment of action steps and objectives

The provider was deficient in meeting this standard because individual written treatment plans did not contain the following:
• Statement of objectives for participant files
• Action steps or target dates for participant file
• Update target date for participant files

Deficiencies 2

7) Section 12070(b) Recovery or Treatment Planning

The above section states, in part, “Staff shall develop the initial treatment plan with input from the participant within 14 days from the date of the participant’s admission.”

The provider was deficient in meeting this standard because an initial treatment plan with input from the participant was not created within 14 days from the date of admission for participant.

8) Section 12070(b) Recovery or Treatment Planning

The above section states, in part; “Staff shall review and update the treatment plan when a change in problem identification or focus of recovery or treatment occurs or no later than 90 days after signing the initial treatment plan”

The provider was deficient in meeting this standard because an updated treatment plan with input from the participant was not created within 90 days of signing the initial treatment plan for participant.

9) Section 12080 Continuing Recovery or Treatment Exit Plan

The above section states, in part, “Program staff shall meet with each participant to develop and document an individualized strategy that will assist the participant in maintaining a continued alcohol and drug free lifestyle.”

The provider was deficient in meeting this standard because treatment exit plans were not included in any participant files.

10) Section 17010 Program Policies

The above section states, in part, “Each program shall have written policies and procedures contained in an operation manual that is located at each certified site and shall be available to staff and volunteers.”

The provider was deficient in meeting this standard because policies and procedures contained in an operation manual were not provided at the certified site.

Deficiencies 3

11) Section 17015(b) Participant Files

The above section states, in part, “At minimum, each participant file shall contain:

*. Demographic and identifying data
* Other Data
* Consent to follow up

The provider was deficient in meeting this standard because the following items were not contained in the participant files:
• Demographic and identifying data for participants
• Consent to follow up for all participants

12) Section 17020 Continuous Quality Management

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

The provider was deficient in meeting this standard because staff was not conducting quality assurance reviews on participant files.

13) Section 19005(b) Personnel Policies

The above section states, in part, “The program shall maintain personnel files for all employees. Each personnel file shall contain: 4. Salary schedule and salary adjustment information, 5. Employee. evaluations, 6. Health records”

The provider was deficient in meeting this standard because the following items were not contained in the personnel files:
• Salary schedule and adjustment information for employees 1, 2, 3, 4, 6, and 7
• Employee evaluations for all employees
• Health records for employees 1, 2, 4, 5, 6, 7, and 8

14) Section 19020(a) Staff Training

The above section states, in part, “The program shall have a written plan that is annually updated, for the training needs of staff.”

The provider was deficient in meeting this standard because verification of training was not provided for employees 1, 3, 4, 5, and 6.

Deficiencies 4

15) Section 21000(a) Admission Agreement

The above section states, in part, “The admission agreement shall inform the participants of the following: Fees assessed for services provided.”

The provider was deficient in meeting this standard because the fees assessed for services were not indicated on the admission agreement for all participants.

17) Section 26010(a) Health and Safety

The above section states, in part, “Programs shall be clean, safe, sanitary and in good repair at all times.”

The provider was deficient in meeting this standard because of the following conditions:
• Building B, Serenity – window screen is damaged; ceiling vent damaged
• Building B, Royalty – missing closet door
• Building B, Tigger – missing window screen
• Building C, Purpose – missing window screen
• Building C, Quintessential – missing bathroom window screen; vanity is damaged
• Building C, Nevah’s Angels – vent is obstructed by towel; missing window screen