COLE HOUSE

Published
0.000
Contact Information
Licensee Name
J. COLE RECOVERY HOMES, INC
1408 A STREET, ANTIOCH, CA 94509
Facility Name
Identification Number
070034AP
Reviews & Findings
Dates of Review
1-Mar-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10513 Adherence to Express Conditions of Licensure Class B

The above section states, in part, ”A licensee shall not operate a facility beyond the conditions and limitations specified on the license.”

The licensee was deficient in meeting the above regulation because the program was storing an abundant amount of loose medication in a large clear plastic bag without proper labeling.

2) Title 9, Section 10563 Accountability Class B

The above section states, in part, “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 licensee was deficient in meeting the above regulation because the program did not contain documentation of a medication refusal policy and procedure. Residents that refused or missed medication were documented in their file but not on the daily medication log.

3) Title 9, Section 10564(e)(1) Personnel Requirement Class B

The above section states, in part, “shall maintain personnel shall be in good health…good physical health shall be verified by a health screening, including a test for tuberculosis.”

The licensee was deficient in meeting the above regulation because the personnel record did not contain a health screening or updated tuberculosis test, for:

• Employee numbers 1 and 6 – missing health screenings
• Employee#’s and – missing updated tuberculosis tests

4) Title 9, Section 10564 (I)(3)(A) Personnel Requirement Class C

The above section states, in part, “shall maintain personnel records staff who provide counseling service, documentation of licensure, certification, or registration to obtain certification.”

The licensee was deficient in meeting the above regulation because the personnel records did not contain documentation of licensure, certification,or registration to obtain certification pursuant to Chapter 8, Section 13035 (f), for Employee #2.

5) Title 9, Section 10567(b) Resident Health Screening Class B

The above section states, in part, “Every resident shall be tested for within six (6) months prior to thirty (30) days after admission and annually thereafter.”

The licensee was deficient in meeting the above regulation because the residents were not tested for tuberculosis within 6 months prior to or 30 days after admission for Resident.

6) Title 9, Section 10572(9) Health-Related Services Class B

The above section states, in part, “Prescription medications which are not removed by the resident upon termination shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a resident. Both shall sign a record, to be retained for at least one (1) year.”

The licensee was deficient in meeting the above regulation because the program’s medication policy and procedure states, “All medications remaining in this facility for 30 days after a discharge will be disposed of.” After talking with staff, the program holds on to medication for 90 days. Staff procedure does not comply with the program’s policy and procedure.

The program does not contain a destruction policy and procedure that complies with this section and identifies the following:

1. Name of resident.
2. The prescription number and the name of the pharmacy.
3. The drug name, strength and quantity destroyed.
4. The date of destruction.

7) Title 9, Section 10581(a) Building and Grounds Class C

The above section states, in part, “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 licensee was deficient in meeting the above regulation because the program is not clean, safe, sanitary, and/or has damage in the following areas:

• There was a 3″x 3″ hole at the bottom of the wall in the hallway outside the kitchen/group room.

8) Title 9, Section 10584(e) Fixtures, Furniture, Equipment and Supplies Class C

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

The licensee was deficient in meeting the above regulation because the program is not clean, safe, sanitary, and/or has damage in the following areas:

• Kitchen – blinds were damaged.
• Manager’s room – blinds were damaged.

Back Unit
• Outlet cover was missing.
• Hole in carpet at base of bunk bed. Upper Unit
• Bathroom – wall outside of shower/tub had water damage.
• Shower/tub was molded and caulk was peeling.
• The wall paint around the sink was peeling.

Deficiencies 2

1) Section 12070(a) Recovery or Treatment Planning

The above section states, in part, “The program shall provide services to ensure that all program participants develop recovery or treatment plans.”

The provider was deficient in meeting the above standard because the program did not assure that treatment plans specifically ident ify the following:

• Resident #’s and – were missing target date(s) for accomplishment of action steps and objectives.

2) Section 19005(b)(1-7) Personnel Policies

The above section states, in part, The program shall maintain personnel files for employees. Each personnel file shall contain:
* Application tor employment and resume
* Employment confirmation statement
* Job description
* Employee evaluations

The provider was deficient in meeting the above standard because the following items were missing from the employee’s file:

(1) Employee numbers 2, 4, 5, 6, 7 and 8 – were missing evaluations.

3) Section 22000(a) Participant Rights

The above section states, in part, “Each participants shall have rights.”

The provider was deficient in meeting the above standard because the participant rights were missing the following statements:

• To be free from verbal, emotional, physical abuse and/or inappropriate/sexual behavior.

• To be accorded access to his or her file.

4) Section 24000 Confidentiality

The above section states, in part, “Confidentiality of participants, participant’s files and information is assured.”

The provider was deficient in meeting the above standard because the program did not have a written statement regarding confidentiality when answering the telephone.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 17
Census: 8

TREATMENT CAPACITY:
Approved: 16
Census: 7