Fred Brown’s Recovery Services

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Published
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Contact Information
Licensee Name
Fred Brown's Recovery Services, Inc.
856 West 19th Street, San Pedro, CA 90731
Facility Name
Identification Number
190135EN
Reviews & Findings
Dates of Review
24-Aug-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

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 not more than sixty (60) days prior to or seven (7) days after employment with tuberculosis testing renewable every year. Personnel with a known record of tuberculosis or record of positive testing shall not be required to be retested if a physician verifies the individual has been under regular care and monitoring for tuberculosis. Such verification will be renewed annually.”

The licensee was deficient in meeting this regulation because there was no current tuberculosis test for employee number one.

Deficiencies 2

1) Section 12030 Communicable Diseases

The above section states, ”All programs shall have a policy that requires participants who show signs of any communicable disease, or through medical disclosure during the intake process, admit to a health related problem that would put others at risk, to be cleared medically before services are provided by the program.”

The provider was deficient in meeting the above standard because the communicable diseases policy did include a section stating that a resident needs to be medically cleared before services would be provided by the program.

2) Section 17020(a)(2-7) Continuous Quality Management

The above section states, in part, “Each program shall maintain written policies and procedures for continuous quality management and shall document in participant file compliance with the procedures. The procedures shall include the following (a) Continuity of Activities. The program shall provide for a staff person (or persons) to monitor and.assure .that the following activities take place (2) The services required are provided and documented in the participant’s file; (3) Failure of the participant to keep scheduled appointments is discussed with the participant and other action taken as appropriate and the discussion and action documented in the participant’s fife; (4) Progress in achieving the objectives identified in the recovery or treatment plan is assessed and documented within the timeframe specified in Section 12070 b. 3.8. or Section 12070 b.4.8. of these Standard; (5) The recovery or treatment plan is reviewed by the participant and updated as necessary at feast every 90 days; (6) The participant’s fife contains all required documents identified in Section 17015; and (7) ff feasible, the participant is followed-up after completion of program services as scheduled in the discharge summary.”

The provider was deficient in meeting this standard because there were no written policies and procedures covering the following:

– Continuity of Activities. The program shall provide for a staff person (or persons) to monitor and assure that the following activities take place:
– The services required are provided and documented in the participant’s file.
– Failure of the participant to keep scheduled appointments is discussed with the participant and other action taken as appropriate and the discussion and action documented in the participant’s file.
– Progress in achieving the objectives identified in the recovery or treatment plan is assessed and documented within the timeframe specified in Section 12070 b. 3.B. or Section 12070 b.4.B. of these Standards.
– The recovery or treatment plan is reviewed by the participant and updated as necessary at least every 90 days.
– The participant’s file contains all required documents identified in Section 17015; and Section 19005(b)(5) Employee evaluations”

The provider was deficient in meeting this standard because the personnel files for employees numbered and contain outdated evaluations.

4) Section 24000 Confidentiality

The above section states, in part, “A written statement regarding confidentiality when answering the telephone and confidentiality regarding files shall be included in the program’s operations participant files shall be accessible only to authorized personnel.”

The provider was deficient in meeting above standard because there was rio written statement regarding confidentiality when answering the telephone in the program’s operation manual.

**This deficiency was cleared on site**

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 12
Census: 12

TREATMENT CAPACITY:
Approved: 12
Census: 12