Jason's Retreat

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Contact Information
Licensee Name
Bakersfield Recovery Services, Inc.
504 Bernard Street, Bakersfield, CA 93305
Facility Name
Identification Number
150004CN
Reviews & Findings
Dates of Review
19-Apr-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Title 9 CCR, Section 10125 Counselor Certification

The above section states, in part “Personnel records for staff who provide counseling services (as defined in section 13005) shall also contain (A) Written documentation of licensure, certification, or registration to obtain certification,”

The provider was deficient in meeting this standard because verification of current certification and/or registration was not contained in the personnel file for employees 2 and 5.

2) Section 12020 Health Questionnaire

The above section states, in part “Program staff shall review each completed health questionnaire. When appropriate, the participant shall be referred to licensed medical professionals for physical and laboratory examinations. A medical clearance or release shall be obtained prior to admission whenever a participant is referred to licensed medical professionals for physical and laboratory examinations. The referral and clearance shall be documented in the participant’s file.”

The provider was deficient in meeting this standard because referrals and clearances were not documented in any participant files.

3) Section 12015(a) Intake

The above section states, in part, “If a participant is appropriate for treatment, the following information shall be gathered 7. Previous Treatment.”

The provider was deficient in meeting this standard because previous treatment information was not gathered and/or contained in any participant files.

4) Section 12050 Referral For Medical or Psychiatric Evaluation and Emergency Services

The above section states, in part, “The program shall have readily available the name, address, and telephone number of the fire department, a crisis center, local law enforcement, and a paramedical unit or ambulance service.”

The provider was deficient in meeting this standard because these services were not posted or provided in any participant files.

5) Section 12055 Referral Arrangements

The above section states, in part, “The program shall maintain and make available to participants a current list of resources within the community that offer services that are not provided within the program. At a minimum, the list of resources shall include medical, dental, mental health, public health, social services and where to apply for the determination of eligibility for State, federal, or county entitlement programs.”

The provider was deficient in meeting this standard because these services were not made readily available.

6) Section 12070(a) Recovery or Treatment Planning

The above section states, in part, “The recovery or treatment plan shall include the following … 3. Action steps taken by program and/or participants to accomplish the identified objectives; 4. Target date(s) for accomplishment of action steps and objectives.”

The provider was deficient in meeting this standard because an individual written treatment plan did not contain action steps or target dates for any of the participant files.

Deficiencies 2

7) Section 12085(a)(b) Discharge Summary

The above section states, in part, “Each program shall have written procedures regarding participant discharge. These procedures shall contain the following a written criteria for discharge defining; 4. Transfers and referrals; b. A discharge summary that includes; 3. Vocational and educational achievements; 6. Participant’s continuing recovery or treatment exit plan.”

The provider was deficient in meeting this standard because transfers and referrals, vocational and educational achievements, as well as treatment exit plans were not contained in participant files.

8) Section 17015(b) Participant Files

The above section states, in part, “At minimum, each participant file shall contain 3. Other Data: I. Consent to follow-up.”

The provider was deficient in meeting this standard because a consent to follow-up was not contained in any participant files.

9) 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: 4. Salary schedule and salary adjustment information 5. Employee evaluations.

The provider was deficient in meeting this standard because the following items were not contained in the personnel files:
• Salary schedule and adjustment information for employee 5.
• Employee evaluations for employees 2, 3, 4, 5.

10) Section 19010(b) Code of Conduct

The above section states, in part, “The code of conduct shall include 6. Conflict of interest.”

The provider was deficient in meeting this standard because the code of conduct did not include a conflict of interest statement.

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

The above section states, in part, “All staff and volunteers whose functions require or necessitate contact with participants or food preparation shall be tested for tuberculosis…and renewed annually from the date of the last tuberculosis test.”

The provider was deficient in meeting this standard because verification of current tuberculosis test results was not contained in the personnel file for employee.

12} Section 19020(a) Staff Training

The above section states, in part,u 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 verification of training was not provided for employee numbers 3 and 5.

13} Section 21000(a) Admission Agreement

The above section states, in part, “The admission agreement shall inform the participants of the following: Fees assessed for services provided.”

The provider was deficient in meeting this standard because the fees assessed for services were not indicated on the admission agreement for all participants.