Magnolia Women’s Recovery Program

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Contact Information
Licensee Name
Magnolia Women's Recovery Programs, Inc.
682 Briergate Way, Hayward, CA 94544
Facility Name
Identification Number
010081AN
Reviews & Findings
Dates of Review
10-Mar-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10563 Accountability Class B

The above section states, in part, “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 the above regulation because the program manual does not contain documentation of a refusal policy.

2) Title 9, Section 10563 Accountability Class B

The above section states, in part, “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 the above regulation because the analyst reviewed the Centrally Stored Medication log. The medication log did not contain documentation for missed/refused medication, as explained to staff.

3) Title 9, Section 10664(b)(3) Personnel Requirement Class C

The above section states, in part, “All personnel shall be trained or shall have experience which provides knowledge of the skills required to the job assigned.”

The licensee was deficient in meeting the above regulation because Employee #7 personnel record did not contain training documentation, experience or knowledge, as required, in this section of the following (A-G):

(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.
(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.

4) Title 9, Section 10564(k) Personnel Requirement Class C

The above section states, in part, “The licensee shall develop, maintain, and implement an ongoing training program for all staff in the areas identified in section 10564(b)(3) of this sub chapter in addition to specific training related to their duties.”

The licensee was deficient in meeting the above regulation because the program did not have documentation of a developed, maintained and implemented ongoing training program for all staff.

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

The above section states, in part, “Personnel records shall be completed and maintained for each employee, shall be available to the department for review.”

The licensee was deficient in meeting the above regulation because the personnel record did not contain documentation of the following:
• No resume for employee #6.
• No job description/duty statement for employee numbers 6 and 8.

***corrected during review***

Deficiencies 2

6) Title 9, Section 10572(b) Health Related Services Class C

The above sections states, in part, “During the provision services there shall be at least one person in the facility who is capable of providing cardiopulmonary resuscitation and first aid. Individuals providing cardiopulmonary resuscitation and first aid shall be qualified by the American Red Cross or other recognized agencies.”

The licensee was deficient in meeting the above regulation because the personnel record did not contain documentation of a current First Aid and CPR certification, during the provision of services for: Employee #2.

7) 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 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.”

The licensee was deficient In meeting the above regulation because the program’s medication policy and procedure states, “All medications remaining in this facility for 30 days after a discharge will be disposed of.” After talking with staff, the program holds on to medication until the contracted company picks it up (maybe twice a year), but the program policy and procedures did not contain specific information and should have other options.

8) Title 9, Section 10581(a) Building and Grounds Class C

The above section states, in pan, “Facilities shall be clean, safe, sanitary and in good repair all all times for the safety and well-being of residents, employees and visitors.”

The licensee was deficient in meeting the above regulation because the program is not clean, safe, sanitary, and/or has damage In the following areas:

• The paint was peeling in various areas of the resident rooms and facility.
• Base boards were dusty and dirty throughout the resident rooms and facility.

Deficiencies 3

9) Title 9, Section 10584(b) Fixtures, Furniture, Equipment and Supplies Class B

The above section states, in part, “All Windows screens shall be in good repair.”

The licensee was deficient In meeting the above regulation because the windows, window screens, and window sills were dusty and/or dirty throughout the facility.

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

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

The licensee was deficient in meeting the above regulation because the program is not clean, safe, sanitary, and/or has damage in the following bathing areas:

• Bedroom #1 bathroom shower was mildewed inside and out and the floor was dirty.

Deficiencies 4

1) Section 12045(a) Drug Screening

The above section states, in part; “All programs shall have a written policy statement …procedures that protect against the falsification and/or contamination.”

The provider was deficient in meeting the above standard because the program did not have a written policy regarding drug!D.screenlng that protects against the falsification an/or contamination of any body specimen sample collected.

2) Section 12070 (b) Recovery or Treatment Planning

The above section states, in part, “The program shall provide services to ensure that all program participants develop recover and/or treatment plans.”

The provider was deficient In meeting the above standard because the Recovery or Treatment Plan Update (TPU) was not developed within the specified time frames for:

• Resident- admission date, initial treatment plan and last treatment update

The last treatment plan update every 90 days should have been developed no later than

3) Section 12085(a) Discharge Summary

The above section states, in part, “Each program shall have written procedures regarding participant discharge. These procedures shall contain the following.”

The provider was deficient in meeting the above standard because the program did not have written procedures and/or criteria for discharge defining the following:

1. Successful completion of program;
2. Unsuccessful discharge;
3. Involuntary discharge; and
4. Transfers and referrals.

4) Section 12085(b) Discharge Summary
The above section states, in part, “Each program shall have written procedures regarding participant discharge. These procedures shall contain the following.”

The provider was deficient in meeting the above standard because the program did not document the clients discharge summary that shall include:

1. Description of treatment episode 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 successful completion;
6. Participant’s continuing recovery or treatment exit plan;
7. Transfers and referrals; and
8. Participant’s comments.

5) Section 19005 (b)(1-7): Personnel Policies

The above sect/an states, in part, “The program shall maintain personnel flies for all employees. Each personnel file shall contain:
*Application for employment and resume.
*Employment confirmation statement.
*Job description
*Employee evaluations

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 employee #2. (corrected during review)
(2) No salary schedule for all staff. (corrected during review)
(3) No employment confirmation statement for (corrected during review)
(4) No evaluations for employee number 1 and 7 through 9. (to be corrected)

(6) Section 19010(c) Code of Conduct

The above section states, in part, “The program shall post the written code of conduct.”

The provider was deficient in meeting the above standard because the program code of conduct was not posted in a public area that is available to participants.

***corrected during review***

7) Section 19010(d) Code of Conduct

The above section states, in part, “Each staff, paid employee and volunteer shall sign a copy of the code of conduct.”

The provider was deficient in meeting the above standard because all personnel records did not contain documentation of the program’s code of conduct signed and dated by staff.

***corrected during review***

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 6
Census: 6

TREATMENT CAPACITY:
Approved: 6
Census: 6