Singing Trees Recovery Center

Published
0.000
Contact Information
Licensee Name
Singing Trees Recovery Center
2061 Highway101, Garberivlle, CA 95542
Facility Name
Identification Number
120008AP
Reviews & Findings
Dates of Review
29-Jun-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10513 Adherence to Express Conditions of Licensure Class B

The above section states, “A licensee shall not operate a facility beyond the conditions and limitations specified on the license.”

The license was deficient in meeting above regulation because the facility is licensed for 20 treatment beds and there were 22 treatment beds on the premises.

2) 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 above regulation because participant had a prescription for that said take 1, 2 times a day for 5 days. The medication was given 2 times a day for 7 days.

3) 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, and shall contain the following information. Past experience, including types of employment and former employers. Duty statement: All personnel shall have on file the record of the health screening as specified in Section 10564(c)(1), (2) of this sub chapter.”

The licensee was deficient in meeting this regulation because of the following:
1. No resume for employee #’s 1, 2, 3, 4, 6 and 7.
2. No job description/duty statement for employee #’s 1-9.
3. No health screening report for employee #’s 1-9.

4) Title 9, Section 10565(e)(1) Personnel Records Class B

The above section states, in part, “good physical health shall be verified by a health screening, including a test for tuberculosis, performed under licensed medical supervision not more than sixty (60) days prior to or seven (7) days after employment with tuberculosis testing renewable every year. Personnel with a known record of tuberculosis or record of positive testing shall not be required to be retested if a physician verifies the individual has been under regular care and monitoring for tuberculosis. Such verification will be renewed annually.”

The licensee was deficient in meeting this regulation because there was no current tuberculosis test result for.

5) 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 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 above regulation because there was no destruction of medication policy to review.

Deficiencies 2

1) Section 12085(b) Discharge Summary

The above section states, in part, “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) Transfers and referral;sand (8) Participant’s comments.

The provider was deficient in meeting the above standard because the following items were missing from the discharge summary:

(1) Description of treatment episodes or recovery services for participant
(2) Current alcohol and/or other drug usage for participant
(3) Legal status for participant
(4) Reason for discharge for participant
(5) Participant’s comments for participant

2) Section 16000 Detoxification Services

The above section states, in part, “Detoxification services will be designed to administer to the severity of/he participant’s level of intoxication, to achieve a safe and supportive withdrawal from alcohol and/or other drugs, and to effectively facilitate the participant’s transition into ongoing services. Detoxification services may be provided in either a residential or nonresidential setting.. .Program providing detoxification services in a residential setting will be licensed. Nonresidential services will be provided in predetermined regularly scheduled sessions. All detoxification protocols will be documented in the policies and procedures manual. All detoxification services will be documented in the participant file.”

The provider was deficient in meeting the above standard because there was no current Detoxification policy and procedures in the manual.
3) Section 1701O Program Policies

The above section states, in part, “All Program policies and procedures will be contained in an operation manual that is located at each certified site and that will be available to staff and volunteers. The policies and procedures manual will contain but not be limited to the following (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; (6) Use of volunteers; (7) Recreational activities; (8) Detoxification services, if applicable; (9) Program administration; (1OJ Personnel practices; (11) Participant grievances/complaints; (12) Fiscal practices; (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; (19) Use of prescribed medications by participants; (20) Maintenance and disposal of participant fifes; (21) Drug screening; and (22) Code of conduct.”

The provider was deficient in meeting the above standard because the following policy and procedure were missing from the manual:

(1) Program mission and philosophy statement.
(2) Intake.
(3) Discharge.
(4) Individual and group sessions.
(5) Recreational activities.
(6) Participant grievances/complaints.
(7) Continuous quality managements.
(8) Maintenance and disposal of participant files.

4) Section 19005(b) Personnel Policies

The above section states, in part, “The Program will maintain personnel files on all employees. Each personnel file will contain: (1) Application for employment and resume; (2) Employment confirmation statement; (3) Job description; (4) Salary schedule and 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).”

The provider was deficient in meeting the above standard because the following items were missing from the employee’s file:

(1) No resume’ for employee #’s 1, 2, 3, 4, 6, and 7.
(2) No employment confirmation statement employee #’s 1-9.
(3) No job description for employee #’s 1-9.
(4) No salary schedule and salary adjustment information for employee #’s 1-9.
(5) No employee evaluations for employee #’s 1, 2, 3, 4, 5, 6, 7 and 8.

5) Section 19010(d) Code of Conduct

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

The provider was deficient in meeting the above standard because there was no signed copy of the code of conduct in employee #1’s file.

6) Section 19015(a) 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 complete a health screening report or health questionnaire.”

The provider was deficient in meeting the above standard because there was no health screening report in the personnel file for employee #’s 1-9.

7) Section 19015(b) Health Screening and Tuberculosis Requirements

The above section states, in part, “All staff and volunteers whose functions require or necessitate contact with participants or food preparation will be tested for tuberculosis. (1) The tuberculosis test will 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 the above standard because there was no current tuberculosis test
results for employee.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 23
Census: 17

TREATMENT CAPACITY:
Approved: 20
Census: 15