RICHMOND HIGH SCHOOL- OATS PROGRAM

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Published
0.000
Contact Information
Licensee Name
Community Health for Asian Americans
1250 23'' Street, Richmond, CA 94804
Facility Name
Identification Number
070041BN
Reviews & Findings
Dates of Review
3-Mar-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 12030 Communicable Diseases

The above section states, in part,” Programs shall have a policy that requires participants who show any signs of any communicable disease to be cleared.”

The applicant was deficient in meeting the above standard because there was no written documentation regarding Communicable Diseases policy available for review.

2) Section 12040 Medication Policy

The above section states, in part, “All alcohol and/or other drug programs shall have a written policy statement regarding the use of prescribed medications.”

The applicant was deficient in meeting the above standard because there was no written documentation regarding a Medication policy available for review.

7) Section 17005 Program Management

The above section states, in part, “Each program shall comply with all applicable local, state, and federal laws and regulations.”

The applicant was deficient in meeting the above standard because there was no written documentation regarding a policy and procedure to ensure the program is maintained in a clean, safe, sanitary and alcohol and drug-free environment.

8) Section 17010(e) Program Policies

The above section states, in part, “The policies and procedures manual shall contain but not be limited to policies and procedures.”

The provider is deficient in meeting the above standard because the following items were missing from the program policies:

a. Program mission and philosophy statement(s)
b. Program description;
c. Program objectives;
d. Program evaluation plan; and
e. Policies and procedures for:

1. Admission and Readmission;
2. Intake;
3. Discharge;
4. Individual and group sessions;
5. Alumni involvement; missing
6. Use of volunteers; missing
7. Recreational activities;
8. Detoxification services, if applicable; n/a
9. Program administration; missing
10. Personnel practices; incomplete
11. Participant grievances/complaints;
12. Fiscal practices; missing
13. Continuous quality management;
14. Participant rights;
15. Nondiscrimination in provision of employment and services;
16. Confidentiality;
17. Community relations;
18. Maintenance of program in a clean, safe and sanitary physical environment; missing
19. Use of prescribed medication by participants; missing
20. Maintenance and disposal of participant files; incomplete
21. Drug Screening; missing
22. Code of conduct. missing

9) Section 17015{e)(2)(3) Disposal and Maintenance of Participant Files

The above section states, in part, “Closed cases-There shall be a written policy maintenance and disposal shall be stored in an appropriate confidential not less than three years shall be destroyed that ensures the confidentiality.”

The applicant was deficient in meeting the above standard because there was no written documentation of a written policy regarding the disposal of participant files and that participant files are destroyed in a manner that ensures confidentiality of participants.

10) Section 19005(a) Personnel Policies

The above section states, in part, “The program shall establish and maintain personnel policies.”

The applicant was deficient in meeting the above standard because there was no written documentation of the following policies:

• Salary schedules and merit adjustment
• Physical health status including a health screening report or health questionnaire, and tuberculosis test results.

11) Section 19005(b) Personnel Policies

The program shall maintain personnel files on all employees. Each personnel file shall contain the required documents in this section, in its entirety (1-7).

The applicant was deficient in meeting the above standard because there was no personnel file for review of the following documents:

1. Application for employment and resume;
2. Employment confirmation statement;
3. Job description;
4. Salary schedule arid salary adjustment information;
5. Employee evaluations;
6. Health records including a health screening report or health questionnaire, and tuberculosis test results as required; and
7. Other personnel actions (e.g., commendations, discipline, status change, employment incidents and/or injuries).

12) Section 19010(c) Code of Conduct

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

The applicant 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.

13) 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 applicant was deficient in meeting the above standard because documentation of the code of conduct signed by staff was not available for review.

14) Section 19015(a) Health Screening and TB Requirements

The above section states, in part, “All staff and volunteers whose functions require or necessitate contact with participants or food preparation.”

The applicant was deficient in meeting the above standard because there was no documentation of the employees health screening report or health questionnaire available for review.

15) Section 19020(a) Staff Training

The above section states, in part, “The program shall have a written plan that is annually updated.”

The applicant was deficient in meeting the above standard because there was no documentation of a staff training plan that is updated annually.

16) Section 20000 Fiscal Practices

The above section slates, in part,
a. “All programs shall have a written policy for the assessment and collection of fees.”
b. Programs funded through the county shall have a method for assessing fees with a documented approval by the county.

The applicant was deficient in meeting the above standard because there was no documentation of the above “fiscal practices” available for review.

Deficiencies 2

17) Section 21000(a) Admission Agreement

The above section states, in part, “admission agreement signed and dated by the participant shall inform the participants of the following fees assessed for services.”

The applicant was deficient in meeting the above standard because the admission agreement did not inform participants of payments, amount assessed, payment schedule, and/or fee scale.

18) Section 22000(c) Participant Rights

The above section states, in part, “The provider shall post a copy of the participant rights.”

The provider was deficient in meeting the above standard because the participant rights’ was not posted in a location that was visible to participants and general public.

19) Section 26010 Health and Safety

The above section states, in part, “Programs shall be clean, safe and sanitary.”

The applicant was deficient in meeting the above standard because in the room utilized for group services there were two leather chairs broken and damaged which is a safety hazard to clients and staff.

20) Section 26020 Hours of Operation

The above section states, in part, “The hours of operation are posted to inform the general public and participants. When closed the program shall provide information.”

The provider was deficient in meeting the above standard because the hours, short-term emergency counseling or referral services and emergency telephone services were not posted.