Nuestra Casa Recovery Home

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Contact Information
Licensee Name
FresnoCo. Hispanic Commissionon Alcoholand Drug Abuse Services Inc
1414 West Kearney Boulevard, Fresno, CA 93706
Facility Name
Identification Number
100006AN
Reviews & Findings
Dates of Review
2-Feb-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 12070(b)(4)(A)(2) Recovery or Treatment Planning

The above section states, in part,
(b) The process for participant recovery or treatment plans shall be the following:
(4) If a treatment plan is developed:
(A) Staff shall develop the initial treatment plan with input from the participant in accordance with the time frame below:
(2) For long-term residential programs (program duration of 31 days or more) the treatment plan shall be developed
within 14 days from the date of the participant’s admission.”

The provider was deficient in meeting this standard because an initial treatment plan, due no later than 1/1/2016 was not in the participant file – participant number

2) Section 12070(b)(5) Recovery or Treatment Planning

The above section states, in part,
(b) The process for participant recovery or treatment plans shall be the following:
(5) 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 nor dated by the counselor participant number

3) Section 12080 Continuing Recovery or Treatment Exit Plan

The above section states, “Before active program participation is concluded and prior to program approved discharge, program staff shall meet with each participant to develop and document an Individualized strategy that will assist the participant in maintaining a continued alcohol and drug free lifestyle. The continuing recovery or treatment exit planning process shall be inclusive of the goals identified in the recovery or treatment plan and shall include referrals to appropriate resources (e.g., social services, MediCal and vocational rehabilitation, and others).

The provider was deficient in meeting this standard because no such exit plan was included in the participant file for those participants who had successfully completed the program, participant numbers .

4) Section 12085(b) Continuing Recovery or Treatment Exit Plan

The above section states, in part
(b) A discharge summary that includes:
1. Description of treatment episodes or recovery services;
2. Current alcohol and/or 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 this standard because a discharge summary documenting all the above required elements was missing from the participant file, participant number

Deficiencies 2

5) Section 17010(e)(21) Program Policies

The above section states, in part,
(e) Policies and procedures for:
(21) Drug screening;

The provider was deficient in meeting this standard because the policy/procedure manual did not include in its policy and/or procedures regarding drug screening the possibility of the participant disputing the results of the test (i.e. what is the next step(s) in resolving the disputed test result).

6) Section 17015(b)(3)(C) Participant Files

The above section states, in part,
(b) At a minimum, each participant file shall contain the following:
(3) Other Data
(C) Individual recovery or treatment plans.

The provider was deficient in meeting this standard because: Refer to Deficiency #1.

7) Section 17015(b)(4)(A) Participant Files

The above section states, in part,
(b) At a minimum, each participant file shall contain the following:
(4) Closed File Data
(A) Continuing recovery or treatment exit plans written prior to discharge

The provider was deficient in meeting this standard because: Refer to Deficiency #3.

Deficiencies 3

8) Section 17015(b)(4)(8) Participant Files

The above section states, in part,
(b) At a minimum, each participant file shall contain the following
(4) Closed File Data
(B) Discharge summary including the date and reason for discharge

The provider was deficient in meeting this standard because: Refer to Deficiency #4.

9) Section 17015(d)(2) Participant Files

The above section states, in part,
(d) Other requirements
(2) All entries shall be signed and dated.

The provider was deficient in meeting this standard because: Refer to Deficiency #2.

10) Section 17020(a)(1) Continuous Quality Management

The above section states, in part,
(a) Continuity of Activities
(1) A recovery or treatment plan is developed within the timeframe specified in Section 12070b.3.A or Section 12070b.4.A of
these Standards.

The provider was deficient in meeting this standard because: Refer to Deficiency #1.

11) Section 17020(a)(6) Continuous Quality Management

The above section states, in part,
(a) Continuity of Activities
(6) The participant’s file contains all required documents identified in Section 17015; and”

The provider was deficient in meeting this standard because: Refer to Deficiencies #1, #3 and #4.

12) Section 19005(b)(5) Personnel Policies

The above section states, in part,
(b) The program shall maintain personnel files on all employees. Each personnel file shall contain:
(5) Employee evaluations

The provider was deficient in meeting this standard because the personnel file did not contain annual performance evaluations for employee numbers #2, #4, #5, #6, and #8.

Deficiencies 4

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 the policy and/or procedure manual did not contain a policy and/or procedure for the safe destruction of medications. This policy and/or procedure should include how this will be accomplished, by who., and a form to document the destruction of the medications.

2) Title 9, Section 10565(a)(2) Personnel Records Class C

The above section states, in part,
(a) Personnel records shall be completed and maintained for each employee, shall be available to the department for review, and
shall contain the following information:
(2) Driver’s license number, class, and expiration date if the employee is to transport residents.

3) Title 9, Section 10572(g) Health-Related Services Class B

The above section states,
(g) 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 this regulation because: Refer to Deficiency #1.

Deficiencies 5

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 the policy and/or procedure manual did not contain a policy and/or procedure for the safe destruction of medications. This policy and/or procedure should include how this will be accomplished, by who, and a form to document the destruction of the medications.

RESPONSE:
Uncertain as to why the Program Supervisor did not show the Analyst FORM 6 (see attached) indicating the policy and procedure for the safe destruction of medications. In an effort to prevent this from happening again the Executive Director carefully reviewed this section of the regulation along with FORM 6 with the Program Supervisor and has instructed him to ensure full compliance.

2) Title 9, Section 10565(a)(2) Personnel Records Class C

The above section states, in part,
(a) Personnel records shall be completed and maintained for each employee, shall be available to the department for review, and
shall contain the following information:
(2) Driver’s license number, class, and expiration date if the employee is to transport residents.”

The licensee was deficient in meeting this regulation because a current California driver’s license was missing from the personnel file, for employee numbers #2, #4, #5, #6, #7, and #8.

RESPONSE:
It has always been the practice of the agency to keep condensed personnel files at the program, however complete personnel files (including Drivers License and Auto Insurance) are kept under lock and key in the HR Managers office in Administration. During site reviews the HR Manager or designated staff avails all (8) program personnel files to the analyst upon request. In an effort to prevent this from happening again the Executive Director has instructed the Program Supervisor and HR Manager to ensure complete personnel files are available to all State and County Analysts when requested. For the record the program only allows the Program Supervisor to transport residents.

3) Title 9, Section 10572(g) Health-Related Services Class B

The above section state,
(g) 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 recotrl, to be retained for at least one (1) year, which lists the following:
(1) Name of/he resident.
(2) The prescription number and the name of the pharmacy.
(3) The drug name, strength and quantify destroyed.
(4) The date of destruction.

The licensee was deficient in meeting this regulation because: Refer to Deficiency #1. RESPONSE:
Uncertain as to why the Program Supervisor did not show the Analyst FORM 6 (see attached) indicating the
policy and procedure for the safe destruction of medications. In an effort to prevent this from happening again the Executive Director carefully reviewed this section of the regulation along with FORM 6 with the Program Supervisor and has instructed him to ensure full compliance.

Deficiencies 6

1) Section 12070(b)(4)(A)(2) Recovery or Treatment Planning

The above section states, in part,
(b) The process for pa,participant recovery or treatment plans shall be the following:
(4) If a treatment plan is developed:
(A) Staff shall develop the initial treatment plan with input from the participant in accordance with the time frame below:
(2) For long-term residential programs (program duration of 31 days or more) the treatment plan shall be developed
within 14 days from the date of the participants admission.

The provider was deficient in meeting this standard because an initial treatment plan, due no later than was not in the participant file – participant number

RESPONSE:
In order to prevent any further noncompliance the Executive Director carefully reviewed each deficiency individually with the Program Supervisor along with the above regulation and reminded him of the severity of this finding. The ED also instructed the Program Supervisor to ensure all Quality Assurance is done according to schedule either by him or a designated person. Given the number of findings in this area.

The ED has reprimanded the Program Supervisor for failing to comply with said regulation and informed him that failure to comply can result in further disciplinary action up to and including termination.

2) Section 12070(b)(5) Recovery or Treatment Planning

The above section states, in part,
(b) The process for part;participant recovery or treatment plans shall be the following:
(5) 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 nor dated by the counselor, participant number

RESPONSE:
In an effort to prevent any further noncompliance in this section the Executive Director has carefully reviewed each deficiency individually with the Program Supervisor along with•the above regulation and instructed the him to ensure all Quality Assurance is done according to schedule either by him or a designated person. Given the nature of this finding in this area the ED has reprimanded the Program Supervisor for failing to comply with said regulation.

3) Section 12080 Continuing Recovery or Treatment Exit Plan

The above section states, “Before active program participation is concluded and prior to program approved discharge, program staff shall meet with each participant to develop and document an individualized strategy that will assist the participant in maintaining a continued alcohol and drug free lifestyle. The continuing recovery or treatment exit planning process shall be inclusive of the goals identified in the recovery or treatment plan and shall include referrals to appropriate resources (e.g., social services, Medi-Cal and vocational rehabilitation, and others).

The provider was deficient in meeting this standard because no such exit plan was included in the participant file for those participants who had successfully completed the program, participant numbers.

RESPONSE:
After the compliance review the Executive Director carefully scrutinized each deficiency individually with the Program Supervisor along with the above regulation and instructed him to ensure all Quality Assurance is done according to schedule either by him or a designated person. The ED will also be conducting unannounced QA to prevent any further noncompliance, In light of these findings the ED has decided to discipline the Program Supervisor for failing to comply with and other regulations.

4) Section 12085(b) Continuing Recovery or Treatment Exit Plan

The above section states, in part,
(b) A discharge summary that includes:
1. Description of treatment episodes or recovery services;
2. Current alcohol and/or 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 ex;f plan;
7. Transfers and referrals; and
8. Participant’s- comments.

The provider was deficient in meeting this standard because a discharge summary documenting all the above required elements was missing from the participant file, participant number

RESPONSE:
After the compliance review the Executive Director carefully scrutinized each deficiency individually with the Program Supervisor along with the above regulation and instructed him to ensure all Quality Assurance is done according to schedule either by him or a designated person. The ED will also be conducting unannounced QA to prevent any further noncompliance. In light of this finding the ED has disciplined the Program Supervisor for failing to comply with said regulations and informed him that failure to comply can result in further disciplinary action up to and including termination.

5) Section 17010(e)(21) Program Policies

The above section states, in part,
(e) Policies and procedures for:
(21) Drug screening

The provider was deficient in meeting this standard because the policy/procedure manual did not include in its policy and/or procedures regarding drug screening the possibility of the participant disputing the results of the test (i.e. what is the next step(s) in resolving the disputed test result).

RESPONSE:
Since the compliance review the program has updated the policy/procedure manual to include a policy and procedure for regarding drug screening should the participant dispute the results of the test. See attached.

6) Section 17015(b)(3)(C) Participant Files

The above section states, in part,
(b) At a minimum, each participant file shall contain the following:
(3) Other Data
(C) Individual recovery or treatment plans.

The provider was deficient in meeting this standard because: Refer to Deficiency #1.

RESPONSE:
In order to prevent any further noncompliance the Executive Director carefully reviewed each deficiency individually with the Program Supervisor along with the above regulation and reminded him of the severity of this finding. The ED also instructed the Program Supervisor to ensure all Quality Assurance is done according to schedule either by him or a designated person. Given the number of findings in this area. The ED has reprimanded the Program Supervisor for failing to comply with said regulation and informed him that failure to comply can result in further disciplinary action up to and including termination. The ED will also be conducting unannounced QA to prevent any further noncompliance.

7) Section 17015(b)(4)(A) Participant Files

The above section states, in part,
(b) At a minimum, each participant file shall contain the following:
(4) Closed File Data
(A) Continuing recovery or treatment exit plans written prior to discharge;” The provider was deficient in meeting this
standard because: Refer to Deficiency #3.

RESPONSE:
Executive Director carefully reviewed each deficiency individually with the Program Supervisor along with the above regulation and reminded him of the severity of this finding and other similar findings. The ED also instructed the Program Supervisor to ensure all Quality Assurance is done according to schedule either by him or a designated person. The ED has decided to conduct unannounced QA to prevent any further noncompliance. Given the number of findings in this area the ED has reprimanded the Program Supervisor for failing to comply with said regulation and informed him that failure to comply can result in further disciplinary action up to and including termination.

8) Section 17015(b)(4)(B) Participant Files

The above section states, in part,
(b) At a minimum, each participant file shall contain the following:
(4) Closed File Data
(B) Discharge summary including the date and reason for discharge

The provider was deficient in meeting this standard because: Refer to Deficiency #4.

RESPONSE:
After the compliance review the Executive Director carefully scrutinized each deficiency individually with the Program Supervisor along with the above regulation and instructed him to ensure all Quality Assurance is done according to schedule either by him or a designated person. The ED will also be conducting unannounced QA to prevent any further noncompliance. In light of this finding the ED has disciplined the Program Supervisor for failing to comply with said regulations and informed him that failure to comply can result in further disciplinary action up to and including termination.

9) Section 17015(d)(2) Participant Files

The above section states, in part,
(d) Other requirements
(2) All entries shall be signed and dated.

The provider was deficient in meeting this standard because: Refer lo Deficiency #2.

RESPONSE:
In an effort to prevent any further noncompliance in this section the Executive Director has carefully reviewed each deficiency individually with the Program Supervisor along with the above regulation and instructed the him to ensure all Quality Assurance is done according to schedule either by him or a designated person. Given the nature of this finding in this area the ED has reprimanded the Program Supervisor for failing to comply with said regulation… .

Deficiencies 7

10) Section 17020(a)(1) Continuous Quality Management

The above section states, in part,
(a) Continuity of Activities
(1) A recovery or treatment plan is developed within the time frame specified in Section 12070b.3.A or Section 12070b.4.A of
these Standards.

The provider was deficient in meeting this standard because: Refer to Deficiency #1.

RESPONSE:
In order to prevent any further noncompliance the Executive Director carefully reviewed each deficiency individually with the Program Supervisor along with the above regulation and reminded him of the severity of this finding. The ED also instructed the Program Supervisor to ensure all Quality Assurance is done according to schedule either by him or a designated person. Given the number of findings in this area. The ED has reprimanded the Program Supervisor for failing to comply with said regulation and informed him that failure to comply can result in further disciplinary action up to and including termination.

11) Section 17020(a)(6) Continuous Quality Management

The above section states, in part,
(a) Continuity of Activities
(6) The participant’s file contains all required documents identified in Section 17015

The provider was deficient in meeting this standard because: Refer to Deficiencies #1, #3 and #4.

RESPONSE:
In order to prevent any further noncompliance the Executive Director carefully reviewed each deficiency individually with the Program Supervisor along with the above regulation and reminded him to ensure the treatment plans, exit plans and discharge summaries are in full compliance. The ED obtained a commitment from the Program Supervisor to ensure all Quality Assurance is done according to schedule either by him or a designated person. Given the number of findings in this area the ED has reprimanded the Program Supervisor for failing to comply with said regulation and informed him that failure to comply can result in further disciplinary action up to and including termination.

12) Section 19005(b)(5) Personnel Policies

The above section states, in part,
(b) The program shall maintain personnel files on all employees. Each personnel file shall contain
(5) Employee evaluations;

The provider was deficient in meeting this standard because the personnel file did not contain annual performance evaluations for employee numbers #2, #4, #5, #6, and #8.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 18
Census: 7

TREATMENT CAPACITY:
Approved: 16
Census: 5