Community Recovery Center East

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Published
0.000
Contact Information
Licensee Name
The West Oakland Health Council
7501 International Boulevard, Oakland, CA 94621
Facility Name
Identification Number
010005FN
Reviews & Findings
Dates of Review
12-Jul-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 12045(b) Drug Screening

The above section states, in part, “All programs shall have a written policy statement regarding drug screenings. The program shall be document results of the drug screening in the participant’s file.”

The provider was deficient in meeting this standard because drug screening results were not contained in the participant files.

2) Section 12070(a)(4) 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 treatment plan shall include the following: Target date(s) for accomplishment of action steps and objectives.”

The provider was deficient in meeting this standard because the treatment plan did not include updated target dates for participant files.

Deficiencies 2

3) Section 12070(b)(3) Recovery or Treatment Planning

The above section states, in part, “The participant shall review his/her progress in achieving the of the treatment plan with staff in accordance with the time frame below. For nonresidential programs the participant’s progress shall be reviewed and documented within 30 days after signing the initial treatment plan and not later than every 30 days after that.”

The provider was deficient in meeting this standard because the treatment plan was not reviewed and documented within 30 days of the initial treatment plan for participant files.

4) Section 12085(b)(6) Discharge Summary

The above section states, in part, “Each program shall have…(b)A discharge summary that includes: 6. Participant’s continuing recovery or treatment exit plan.”

The provider was deficient in meeting this standard because the participant’s continuing recovery or treatment exit plan was not contained in participant file.

5) Section 17010(a) Program Policies

The above section states, in part, “The policies and procedures manual shall contain but not be limited to a program mission and philosophy statements.”

The provider was deficient in meeting this standard because the policies and procedures manual did not include program mission and philosophy statements.

6) Section 17010(b) Program Policies

The above section states, in part, “The policies and procedures manual shall contain but not be limited to program description.”

The provider was deficient in meeting this standard because the policies and procedures manual did not include a program description.

Deficiencies 3

7) Section 17010(c) Program Policies

The above section states, in part, “The policies and procedures manual shall contain but not be limited to program objectives.”

The provider was deficient in meeting this standard because the policies and procedures manual did not include program objectives.

8) Section 17010(d) Program Policies

The above section states, in part, “The policies and procedures manual shall contain but not be limited to program evaluation plan.”

The provider was deficient in meeting this standard because the policies and procedures manual did not include a program evaluation plan.

9) Section 17010(e) Program Policies

The above section states, in part, “The policies and procedures manual shall contain but not be limited to policies and procedures for:
• Alumni involvement
• Use of volunteers
• Recreational activities
• Program administration
• Personnel practices
• Fiscal practices
• Continuous quality management
• Participant rights
• Nondiscrimination in provision of employment and services
• Community relations
• Maintenance of program in a clean, safe and sanitary physical environment
• Maintenance and disposal of participant files
• Drug screening

The provider was deficient in meeting this standard because the following were not contained in the policies and procedures manual:

• Alumni involvement
• Use of volunteers
• Recreational activities
• Program administration
• Personnel practices
• Fiscal practices
• Continuous quality management
• Nondiscrimination in provision of employment and services
• Community relations .
• Maintenance of program in a clean, safe and sanitary physical environment.
• Maintenance and disposal of participant files
• Drug screening.

Deficiencies 4

10) Section 17015(b)(3) Participant Files

The above section states, in part, “At minimum, each participant file shall contain:
• Other Data: Medical referrals and clearances;
• Consent to follow-up

The provider was deficient in meeting this standard because the following documents were not contained in participant files:

• Medical referrals and clearances for all participants
• Consent to follow-up for participants

11) 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:
• Application for employment and resume
• Employment confirmation statement
• Employee evaluations
• Health records including a health screening report or health questionnaire, and tuberculosis test results

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

• Job application for employee numbers 1 and 2
• Resume for employee numbers 1 and 5
• Employment confirmation statement employee numbers 1, 2, 4, and 5
• Employee evaluations for employee numbers 1 an 4
• Heath records for employee numbers 1, 2, 4, and 5
• TB test for all employees

12) Section 19010{a) Code of Conduct

The above section states, in part, “The program shall have a written code of conduct that pertains to and is known about by staff, paid employee volunteers.”

The provider was deficient in meeting the above standard because a code of conduct was not contained in personnel files.

Deficiencies 5

13) Section 19010(b):

Code of Conduct

The above section states, in part, “The code of conduct shall include: Conflict of interest and Confidentiality.”

The provider was deficient in meeting the above standard because conflict of interest and confidentiality were not contained in personnel files.

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 the program did not contain a written training plan.

15) Section 19020(a) Staff Training

The above section states, in part, “All staff training events shall be documented and maintained as part of the training plan.”

The provider was deficient in meeting this standard because the program did not document or maintain records for staff training events.

16) Section 21000 Admission Agreement

The above section states, in part, “The program shall have a written admission agreement that shall be signed and dated by the participant and program staff upon admission. The program shall place the original signed admission agreement in the participant’s file and a copy shall be given to the participant.”

The provider was deficient in meeting this standard because an admission agreement was not contained in pa participant’s files.

17) Section 21000 Admission Agreement .

The above section states, in part, “The program shall have a written admission agreement that shall inform the participants of the following:
a. Fees assessed for services provided .

The provider was deficient in meeting this standard because the fees assess for services provided not contained in the participant files.

Detailed Information
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