Northern Valley Indian Heatlh, Inc.

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Published
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Contact Information
Licensee Name
Northern Valley Indian Health, Inc
845 West EastAveune, Chico, CA 95926-2002
Facility Name
Identification Number
040018AN
Reviews & Findings
Dates of Review
2-Nov-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1. Section 12015(a) Intake

The above section states, in part, “If a participant is appropriate for treatment, the following information shall be gathered: 1) Social, economic and family history; 4) Criminal history, legal status; 5) Medical history.”

The provider was deficient in meeting this standard because the social economic and family history information was not documented for Participants.

The provider was deficient in meeting this standard because the criminal history was not documented for Participants.

The provider was deficient in meeting this standard because the medical history was not documented for Participants.

2. Section 12045(b) Drug Screening

The above section states, “All programs shall have a written policy statement regarding drug screening. For those situations where alcohol and/or other drug screening is deemed appropriate and necessary by the program director or designee, or supervising physician, the program shall: Document results of the drug screening in the participant’s files.”

The provider was deficient in meeting this standard because documentation of drug screening results was no contained in the participant files for Participants.

3. Section 12070(a) Recovery or Treatment Planning

The above section states, “The program shall provide services to ensure that all program participants develop recovery or treatment plans. The recovery or treatment plans shall include the following: (1) Statement of problems experienced by the participant to be addressed; (2) Statement of objectives to be reached that address each problem; (3) Action steps that will be taken by program and/or participant to accomplish the identified objectives; and (4) Target date(s) for accomplishment of action steps and objectives.”

The provider was deficient in meeting this standard because target dates were not documented for the treatment plans for Participant

4. Section 12070(b)(4)(A)(3) Recovery or Treatment Planning

The above section states, “The process for participant recovery or treatment plans shall be the following: If a treatment plan is developed: Staff shall develop the initial treatment plan with input from the participant in accordance with the time frame below: For nonresidential programs the treatment plan shall be developed within 30 days from the date of the participant’s admission.”

The provider was deficient in meeting this standard because a recovery/treatment plan was not developed for Participant. The participant initially enrolled into the outpatient program.

5. Section 12070(b)(4)(C) Recovery or Treatment Planning

The above section states, in part, “Staff and the participant shall review and update the treatment plan when a change in problem identification or focus of recovery or treatment occurs, or no later than 90 days after signing the initial treatment plan and no later than every 90 days thereafter, whichever comes first.”

The provider was deficient in meeting this standard because the treatment plan had not been reviewed and updated within 90 days after signing the initial treatment plan for participants

Deficiencies 2

6. Section 12070(b)(4)(C)(5) Recovery or Treatment Planning

The above section states, in part, “Staff and the participant shall review and update the treatment plan when a change in problem identification or focus of recovery or treatment occurs, or no later than 90 days after signing the initial treatment plan and no later than every 90 days thereafter, whichever comes first.”

The initial recovery or treatment plan and any update shall be signed and dated by the participant and staff at the time the recovery or
treatment plan is developed or updated.

The provider was deficient in meeting this standard because the initial treatment plan was not signed and dated by either Participant or the program staff.

7. Section 12085(b) Discharge Summary

The above section states, “Each program shall have written procedures regarding participant discharge. These procedures shall contain the following: (b) A 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) Transfer and referrals; and (8) Participant’s comments.”

The provider was deficient in meeting this standard because the aforementioned information was not document d for Participant following discharge:

• Description of treatment episodes or recovery services
• Current alcohol and/or other drug usage
• Vocational and educational achievements
• Legal status
• Participant’s continuing recovery or treatment exit plan
• Transfers and referrals

8. Section 13000(d){3)(A) Individual and Group Sessions

The above section states, ‘The counselor/program specialist shall document, by signing their name and putting the date on the following information for participant’s attendance at individual and group sessions. This documentation shall be placed in the participant’s file: Progress toward achieving the participant’s recovery or treatment plan goals; Nonresidential programs shall document each participants’ progress for each individual or group session attended.”

The provider was deficient in meeting this standard because progress was not documented for an individual session on for Participant.

The provider was deficient in meeting this standard because progress was not documented for a group session on for Participant

9. Section 13000(e)(2)(A) Individual and Group Sessions

The above section states, in part, “Outpatient: A minimum of two individual group sessions shall be provided for each participant per 30-day period or more often, depending on the participant’s need and recovery or treatment plan.”

The provider was deficient in meeting this standard because Participant group sessions.

The provider was deficient in meeting this standard because Participant group sessions had not attended any individual or had not attended any individual.

10. Section 1701S(b)(3)(1) Participant Files

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

The provider was deficient in meeting this standard because a copy of the consent to follow-up was not contained in the participant files for Participants.

Deficiencies 3

11. Section 19005(b) Personnel Policies

The above section states, in part, “The program shall maintain personnel files on all employees. Each personnel file shall contain: (1) Application for employment and resume; (5) Employee evaluations; and (6) Health records including a health screening report or health questionnaire, and tuberculosis test results as required.”

The provider was deficient in meeting this standard because resumes were not contained in the personnel file for Employees #3, #4, and #6.

The provider was deficient in meeting this standard because an application was not contained in the personnel file for Employee #4.

The provider was deficient in meeting this standard because evaluations were not completed on a yearly basis, per the policy, and procedure manual, for Employees #1 and #2.

The provider was deficient in meeting this standard because the health screening report did not specify that Employee was cleared to perform work duties.

12. Section 19010(d) Code of Conduct

The above section states, “Each staff, paid employee and volunteer shall sign a copy of the code of conduct, and the program shall place the signed copy in the personnel file of the individual.”

The provider was deficient in meeting this standard be use assigned Code of Conduct was not contained in the personnel files for Employees #1, #5, ‘#6, and #7.

13. Section 19015(b)(1) Health Screening and Tuberculosis Requirements

The above section states, “All staff and volunteers whose functions require or necessitate contact with participants or food preparation shall be tested for tuberculosis. The tuberculosis test shall 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 last tuberculosis test.”

The provider was deficient in meeting this standard because the tuberculosis tests for Employees were completed over a year ago.

The provider was deficient in meeting this standard because there was no documentation of tuberculosis tests for Employees and
The provider was deficient in meeting a this standard because there was no result from the tuberculosis;test performed on for Employee.

Deficiencies 4

14. Section 19020(a) Staff Training

The above section states, ‘The program shall have a written plan that is annually updated, for the training needs of staff. All staff training events shall be documented and maintained as part of the training plan.”

The provider was deficient in meeting this standard because ongoing training was not documented for Employees #2, #5, and #7.

15, Section 21000(a) Admission Agreement

The above section states, “The program shall have a written admission agreement that shall be signed and dated by the participant and program staff upon admission. The program shall place the original signed admission agreement In the participant’s file and a copy shall be given to the participant.”

The provider was deficient in meeting this standard because an admission agreement was missing in the participant file for Participant

The provider was deficient in meeting this standard because the admission agreement was not signed or dated by either Participant or the program staff.

The provider was deficient in meeting this standard because the admission agreement was not dated by Participant

16 . Section 26010(a)(1)(F) Health and Safety

The above section states, “program shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of participant employees and visitors. The program shall be free from: Other health or safety hazards.”

The provider was deficient in meeting this standard because electrical sockets were not covered in areas where children are commonly present.