Ruth Ellen Wallace

Published
0.000
Contact Information
Licensee Name
Ruth Ellen Wallace
2057 ForestAvenue, Chico, CA 9592-87627
Facility Name
Identification Number
040031AP
Reviews & Findings
Dates of Review
3-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: 2) Education; 3) Employment history; 4) Criminal history, legal status; 7) Previous treatment.”

The provider was deficient in meeting this standard because information pertaining to education was not gathered for Participants.

The provider was deficient in meeting this standard because criminal history/legal status was not gathered for Participant.

The provider was deficient in meeting this standard because employment history was not gathered for Participant.

The provider was deficient in meeting this standard because previous treatment history was not gathered for Participant.

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 participants files”

The provider was deficient in meeting this standard because documentation of drug screening results were not 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; and (4) Target date(s) for accomplishment of action steps and objectives.”

The provider was deficient in meeting this standard because the treatment/recovery plan did not contain the aforementioned information 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 participants admission.”

The provider was deficient in meeting this standard because a treatment plan was not developed for Participants. The participants signed the admission agreements on and respectively, and a treatment plan had not been developed.

5. Section 1270(b)(4)(C) Recovery or Treatment Planning

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

The provider was deficient in meeting this standard because treatment plan are not being updated by staff.

6. 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 recover/or treatment exit plan. ; (7.)
Transfer and referrals; and (8) Participant’s comments.”

The provider was deficient in meeting this standard because the following information was not documented 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

The provider was deficient in meeting this standard because the discharge paperwork utilized by the provider does not contain information pertaining to current alcohol and/or other drug usage, vocational and educational achievements, and legal status.

7. Section 13000(d). Individual and Group Sessions

The above section states, in part, “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 place in the participant’s file: 1) Date of each session attended; 2) Type of session (i.e. individual or group).”

The provider was deficient in meeting this standard because the date and type of sessions attended are not being documented for Participants.

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 fife: Progress toward achieving the participant’s recovery or treatment plan goals; Nonresidential programs shall document each participant’s progress for each individual or group session attended.”

The provider was deficient in meeting this standard because progress notes are not documented for any individual or group sessions for Participants.

9. Section 17015(b)(1)(D) Participant Files

The above section states, ”At a minimum, each participant file shall contain the following: Demographic and Identifying Data: Race/ethnic backgrounds.”

The provider was deficient in meeting this standard because race/ethnic background information was not contained in the participant files for Participants.

10. Section 17015(b)(2)(F) Participant Files

The above section states, “At a minimum, each participant file shall contain the following: Admission and Intake Data: All data gathered during admission and intake including: Authorization to release information”.

The provider was deficient in meeting this standard because the authorization to release Information was not contained in the participant files for Participants.

11. Section 17015{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 the above standard because a copy of the consent to follow-up was not contained in the participant files for Participants.

12. Section 19005(b) Personnel Policies

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

The provider was deficient in meeting this standard because an employee evaluation had not been provided for Employee #2 for over a year.

13. Section 19010(c) Code of Conduct

The above section states, “The program shall post the written code of conduct in a public area that is available ta participants.”

The provider was deficient in meeting this standard because the written code of conduct was not posted in the facility.

**This deficiency was corrected during the site visit.**

14. Section 19020(a) Staff Training

The above section states, “The program shall have 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 Employee #2.

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 admission agreement shall inform the participants of the following: Fees assessed for services provided. ”

The provider was deficient in meeting this standard because the group participants are considered to be part of the admission agreement. This is not being signed by the program staff.

The provider was deficient in meeting this standard because the fees assessed was not documented in the admission agreement for Participant.

16. Section 21000(f) 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 admission agreement shall inform the participants of the following: Reasons for termination.”

The provider was deficient in meeting this standard because the reasons for termination was not contained in the admission agreement.

17. Section 22000(a) Participant Rights

The above section states, “Each participant shall have rights that include, but are not limited to, the following:

(1) The right to confidentiality as provided for in Title 42, Code of Federal Regulations, Part 2.
(2) To be accorded dignity in contact with staff, volunteers, board members and other persons.
(3) To be accorded safe, healthful and comfortable accommodations to meet his or her needs.
(4) To be free from verbal, emotional, physical abuse and/or inappropriate sexual behavior.
(5) To be informed by the program of the procedures to file a grievance or appeal discharge.
(6) To be free from discrimination based on ethnic group identification, religion, age, sex. Color, or disability.
(7) To be accorded access to his or her file.”

The provider was deficient in meeting this standard because the rights that are provided to participants do not include each of the items in the aforementioned list.

18. Section 22000(c) Participant Rights

The above section states, “The provider shall post a copy of the participant rights in a location visible to all participants and the general public.”

The provider was deficient in meeting this standard because a copy of the participants was not posted in the facility.

**This deficiency was corrected during the site visit.**