Frederic Ozanarn Center

Published
0.000
Contact Information
Licensee Name
Bi-Bett
2931 Prospect Avenue, Concord, CA 94518
Facility Name
Identification Number
070001BN
Reviews & Findings
Dates of Review
25-Jul-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10563 Accountability Class B

The above section states, “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 this regulation because in participant found without dates.

2) Title 9, Section 10563 Accountability Class B

The above section states, “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 this regulation because there was no refrigerator with food and drinks.

3) Title 9, Section 10563 Accountability Class B

The above section states, “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 this regulation because there was outside contracted labor providing overnight staffing.

4) Title 9, Section 10563 Accountability Class B

The above section states, “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 this regulation because they were storing medication for non-residents.

5) Title 9, Section 10564(b)(1){3) Personnel Requirements Class C

The above section states, in part, “(1) Facility personnel including volunteers shall be competent to provide the services necessary to meet resident needs and shall be adequate in numbers necessary to meet such needs. Competence shall be demonstrated by accrued work, personal, and/or educational experience and/or on the job performance. All personnel shall be trained or shall have experience which provides knowledge of the skills required in the following areas, as appropriate to the job assigned, and as evidenced by safe and effective job performance: (A) General knowledge of alcohol and/or drug abuse and alcoholism and the principles of recovery. (B) Housekeeping and sanitation principles. (C) Principles of communicable disease prevention and control. (D) Recognition of early signs of illness and the need for professional assistance. (E) Availability of community services and resources. (F) Recognition of individuals under the influence of alcohol and/or drugs. (G) Principles of nutrition, food preparation and storage, and menu planning.

The licensee was deficient in meeting this regulation because there was no evidence of training or experience for contracted employee numbers 8, 9 and 10.

6) Title 9, Section 10565(e)(1) Personnel Records Class B

The above section states, in part, “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 were no current tuberculosis test results for contracted employees.

7) Title 9, Section 10565(a)(b) Personnel Records Class C

The above section states, in part, “Personnel records shall be completed and maintained for each employee, shalI be available to the department for review, and shall contain the following information: (1) Employee’s full name. (2) Driver’s license number, class, and expiration date if the employee is to transport residents. (3)Date of employment(4) Home address and phone number. (5) Past experience, including types of employment and former employers. (6) Duty statement. (7) Termination date if no longer employed by the facility. All personnel shall have on fife the record of the health screening as specified in Section 10564(c)(1), (2) of this sub chapter.”

The licensee was deficient in meeting this regulation because there was no employee file maintained for contracted employee #’s 8, 9 and 10.

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

The above section states, in part, “During the provision of alcoholism or drug abuse recovery or treatment services as defined in section 10501(a) of this sub chapter there shall be at least one person in the facility who is capable of providing cardiopulmonary resuscitation and first aid, notwithstanding section 10572(b)(1) of this sub chapter. Individuals providing cardiopulmonary resuscitation and first aid shall be qualified by the American Red Cross or other recognized agencies. (1) Facilities providing detoxification services shall ensure
that at least one person is always on the premises who is capable of providing cardiopulmonary resuscitation.

The licensee was deficient in meeting this regulation because there was no first aid for contracted employee number 8, 9 and 10.

9) 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 above regulation because medications were found in the facility that were already signed off as being destroyed.

10) Title 9, Section 10573(a) Food Service Class C

The above section stales, in part, “In facilities providing meals to residents, the following shall apply. “All food shall be selected, stored, prepared and served in a safe and healthful manner.”

The licensee was deficient in meeting above regulation because there were expired canned goods and opened boxes of cereal stored In the pantry.

11) Title 9, Section 10581(a)(3) Buildings and Grounds Class C

The above section states, in part, The facility must be separate and secure. Facility living, sleeping, bathing and toiletry areas shall be enclosed by permanent walls, floors, ceilings and doors.”

The licensee was deficient in meeting above regulation because there were no locks on the bathroom doors.

12) Title 9, Section 10584(c) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, “The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the safety of all persons in the facility.”

The licensee was deficient in meeting above regulation because there was overhead light in the ADA bedroom.

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

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

The licensee was deficient in meeting above regulation because there was mold in the ADA shower.

Deficiencies 2

1) Section 12015(a) Intake

The above section states, in part, “If a participant’s appropriate for treatment, the following information will be gathered: (1) Social, economic and family history; (2) Education; (3) Employment history; (4) Criminal history, legal status; (5) Medical history; (6) Alcohol and/or other drug history; and (7) Previous treatment.”

The provider was deficient in meeting the above standard because participant economic and family history and previous treatment from file.

2) Section 12085(b) Discharge Summary

The above section states, in part, “Discharge summary that includes: (1) Description of treatment episodes or recovery services; (2) Current alcohol and/or other drug usage; (3) Vocational and educational achievements; (4) Legal status; (5) Reason for discharge and whether the discharge was involuntary or a successful completion; (6) Participant’s continuing recovery or treatment exit plan; (7) Transfers and referrals; and (8) Participant’s comments.

The provider was deficient in meeting above standard because the recovery services, current alcohol and/or other drug usage, vocational educational achievement, legal status and reasons for discharge were missing from discharged client.

3) Section 13000(d) Individual and Group Sessions

The above section states, in part, “Residential Program will document each participant’s progress on a weekly basis.

The provider was deficient in meeting the above standard because there were no progress notes documented in the file for participant

4) Section 16000 Detoxification Services

The above section states, in part, “All detoxification services will be documented in the participant file.”

The provider was deficient in meeting the above standard because in participant log was found without dates.

5) Section 16020(c) Residential Detoxification Practices

The above section states, in part, “Each individual will be closely observed and physically checked at feast every 30 minutes during the first 12 hours following admission by a staff person or volunteer. The close observation and physical checks will continue beyond the initial 12-hour period for as long as the withdrawal signs and symptoms warrant. Documentation of the information that supports a decrease in observation and physical checks will be recorded in the participant’s file by a staff person or volunteer. Documentation of observations and physical checks will be recorded in a systematic manner.

The provider was deficient in meeting the above standard because in participant log was found without dates.

6) Section 16030(a) Residential Detoxification Staffing

The above section states , in part, “During the provision of detoxification services, the minimum staffing or volunteer ratios and health-related requirements will be as follows. In a Program with 15 or fewer residents who are receiving detoxification services, there will be at least one staff member or volunteer on duty and awake at all times with a current cardiopulmonary resuscitation certificate and current first aid training.”

7) Section 17015(b) Participant Files

The above section states, in part, “At a minimum, each participant file will contain the following: Consent to follow-up.”

The provider was deficient in meeting the above standard because the consent to follow up was missing for participants.

8) Section 19005(b) Personnel Policies

The above section states, in part, The Program will maintain personnel files on all employees. Each personnel file will contain:
* Application for employment and resume
* Employment confirmation statement
* Job description
* Salary schedule and salary adjustment information
* Employee evaluations
* Health records including a health screening report or health questionnaire, and tuberculosis test results as required.

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

(1) No job application for contracted employee #’s 8, 9 and 10.
(2) No resume’ for contracted employee ‘Ifs 8, 9 and 10.
(3) No employment confirmation statement for contracted employee #’ s 8, 9 and 10.
(4) No job description for contracted employee #’s 8, 9 and 10.
(5) No salary schedule and salary adjustment information for ResCare employee #’s 8, 9 and 10.
(6) No employee evaluations for employee ‘Ifs 1, 2, 3, 5, 6, 7, 8, 9 and 10.
(7) No health screening report or health questionnaire for contracted employee #’s 8, 9 and 10.
(8) No tuberculosis test results as required for contracted employee #’s

9) Section 19015(b) Health Screening and Tuberculosis Requirements

The above section states, in part,u A/1 staff and volunteers whose functions require or necessitate contact with participants or food preparation will be tested for tuberculosis. (1) The tuberculosis test will 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.”

10) Section 26010(a) Health and Safety

The above section states, in part, “Program will be clean, safe, sanitary and in good repair at all times for the safety and welI-being of participants, employees and visitors.

The provider was deficient in meeting the above standard because of the following:

1) There were expired canned goods and open boxes of cereal stored in the pantry.
2) There was one light bulb missing in overhead light in the ADA bedroom.
3) There was mold in the shower of the ADA bathroom.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 6
Census: 4

TREATMENT CAPACITY:
Approved: 6
Census: 4