1) Section 12070(4)(8 )(3) Recovery or Treatment Plan
The above section states, in part, “If a treatment plan is developed: For nonresidential programs the staff shall review the participant’s treatment plan and document progress within 30 days of signing the initial treatment plan and no later that every 30 days thereafter.”
The provider was deficient in meeting this stand and because participant treatment plan reviewed within the specified time frame.
2) Section 12085(b) Discharge Summary
The above section states, “Each program shall have written procedures regarding participant discharge. These procedures shall contain the following: (b) A discharge summary that includes: (8) Participant’s comments.”
The provider was deficient in meeting this standard because the participant’s comments are not documented in the discharge summary.
3) Section 17015(b) Participant Files
The above section states, in part, ”At minimum, each participant file shall contain the following: (2) Admission and Intake Data (G) Participants rights document; (3) Other Data (I) Consent to follow up; (4) Closed File Data (C) Consent to follow-up.”
The provider was deficient in-meeting this standard because of the following:
• Participant rights document meeting requirements of Section 22000 (1-7).
• Consent to follow-up missing from all participant files.
• Consent to follow-up missing from all discharged flies.
4) Section 17020 (a) Continuous Quality Management
The section above states, in part, “Continuity of activities: (6) The participant’s file contain all required documents identified in section 17015.”
The provider was deficient in meeting this standard because a consent to follow-up was missing from all participant’s files.
5) Section 18000 Board of Directors and Community Advisory Board
The above section states, in part, “The name and addresses of all board of directors and community advisory board members shall be available.”
The provider was deficient in meeting this standard because the documentation did not provide the addresses of the community advisory board members.
6) Section 19005(b) Personnel Policies
The above section states, in part, “The program shall maintain personnel files on all employees. Each personnel fife shall contain: (6) Health records including a health screening report or health questionnaire, and tuberculosis test results as required.”
The provide r was deficient in meeting this standard because verification of current tuberculosis test results were not contained in the personnel file for employees.
7) Section 19010(b) Code of Conduct
The above section states, “The code of conduct shall include the program policies regarding at a minimum the following: (1) Use of Alcohol and Drugs on the premises and when off the premises (6) Conflict of Interest; and Confidentiality.”
The provider was deficient in meeting this standard because the code of conduct did not contain the following:
• Use of Alcohol and/or other drugs on the premises and when off the premises;
• Conflict of Interest
**This item was corrected during the site visit.**
8) Section 1901 5(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 fast tuberculosis test.”
The provider was deficient In meeting this standard because verification of current tuberculosis test results were not contained in the personnel files for employees
9) Section 22000(a) Participant Rights
The above section states, “Each participant shall have rights that include, but are not limited to, the following: (1) The right to confidentiality as provided for in Title 42, Code of Federal Regulations, Part 2. (2) To be accorded dignity in contact with staff, volunteers, board members and other persons. (3) To be accorded safe, healthful and comfortable accommodations to meet his or her needs. (4) To be free from verbal, emotional, physical abuse and/or inappropriate sexual behavior. (5) To be informed by the program of the procedures to file a grievance or appeal discharge. (6) To be free from discrimination based on ethnic group identification, religion, age, sex. Color, or disability. (7) To be accorded access to his or her file.”
The provider was deficient in meeting this standard because the rights that are provided to participants do not include each of the items in the aforementioned list.
*** This item was correct during the site visit***
10) Section 26020 Hours of Operation
The above section states, in part, “Each program shall post the hours of operation to inform the general public and participants.”
The provider was deficient in meeting this standard because the hours of operation were not posted.