ELEVATE ADDICTION SERVICES – South Lake Tahoe

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Contact Information
Licensee Name
HALCYON HORIZONS, INCORPORATED
586 Glorena Avenue, South Lake Tahoe, CA 96150-3907
Facility Name
Identification Number
090018CN
Reviews & Findings
Dates of Review
1-Jun-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

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

The above section states, In part,
(e) All personnel shall be In good health.
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis performed under licensed medical supervision more than sixty (60) days prior to or seven (7) days after employment with tuberculosis testing renewable every year.

The licensee was deficient in meeting this regulation because the personnel file did not contain current tuberculosis test results for employees.

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

The above section states, in part, “Prescription medications which are not removed by the resident upon termination of services 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, which lists the following:”

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

The licensee was deficient in meeting this regulation because the medication destruction policy documented in the policy manual is not the current method of medication destruction. Currently only one staff member is signing that medication has been destroyed.
Note: A new form was created prior to the exit interview, in which two staff signatures will now be captured when medication ls destroyed.

Deficiencies 2

1) Section 19005(b)(5) Personnel Policies

The above section states, in part,
(b) The program shall maintain personnel files on all employees, Each personnel file shall contain:
(5) Employee evaluations

The provider was deficient in meeting the above standard because the personnel file did not contain current employee performance valuation (annual requirement) for employees number 6 and 14.

2) Section 19005(b)(6) Personnel Policies

The above section states, in part,
(b) The program $hell maintain personnel files on all employees. Each personnel file shall contain:
(6) Health records including a health screening report or health questionnaire and tuberculosis
test results as require.

The provider was deficient in meeting the .above standard because the personnel file did not contain a current test for tuberculosis (annual requirement) for employees

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 75
Census: 27

TREATMENT CAPACITY:
Approved: 70
Census: 16