Step Ahead Adolescent Outpateint Drug Treatment Program

Published
0.000
Contact Information
Licensee Name
Community Health for Asian Americans
207 37lhStreet., Richmond, CA 94805
Facility Name
Identification Number
070041AN
Reviews & Findings
Dates of Review
28-Sep-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 12070(b)(4)(A)(3) Recovery or Treatment Plan

The above section states, in part, “If a treatment plan is developed: (A) Staff shall develop the initial treatment plan (3) For non-residential programs within 30 days from the date of the participant’s admission.”

The provider was deficient in meeting this standard because the date of initial treatment plan for participant was not developed within 30 days of admission.

2) Section 13000(a)(d)(3)(A) Individual and Group Sessions

The above section states, in part, “The counselor/program specialist shall document, (3) Progress towards achieving the participants recovery or treatment plan goals, (A) 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 not for participant

3) Section 19005(b)(1-7) Personnel Policies

The above section states, in part, “The program shall maintain personnel files for all employees. Each personnel file shall contain (3) Job Description; (5) Employee Evaluations and (6) Tuberculosis Test.”

The provider was deficient in meeting this standard because the following documents were not contained in
the personnel files:

• Job description for employee numbers 1, 2 and 3.
• Evaluations for employee numbers 1 and 3.
• Tuberculosis test results for employees.

4) Section 19010(c) Code of Conduct

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

The provider was deficient in meeting this standard because the code of conduct was not posted In public area.

5) 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 because the following documentation was not contained in the personnel files:

• Code of conduct for employee numbers 2 and # 3.
• Conflict of interest for employee numbers1 and # 3.

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 shall complete a health screening report or health questionnaire.”

The provider was deficient in meeting this standard because no health screening report or health questionnaire was not contained in the personnel file for employee number 2.

7) Section 19015 (b)(1) Health Screening and Tuberculosis Requirements

The above sections states, In part, “All staff and volunteers whose functions require or necessitate contact with participants shall be tested for tuberculosis.”

1) The tuberculosis test shall be conducted under licensed medical supervision on not more than three months prior or seven days after employment and renewed annually from date of the last tuberculosis test.

The provider was deficient in meeting this standard because verification of the tuberculosis test results were not contained in the personnel files for employees.

8) Section 19020(a) Staff Training

The above section states, in part, “A(I staff training events shall be documented and maintained as part of the training program.

The provider was deficient In meeting this standard because documentation of training was not available for review for employee # 2.

9) Section 21000 (a) Admission Agreement

The above section states, in part, “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 admission agreement did not contain fees assessed for services provided tor participants.

10) Section 26010(a) Health and Safety

The above section states, in part, “Programs shall be clean, sanitary and in good repair at all times.”

The provider was deficient in meeting this standard because of the following conditions:

• Bathroom # 1 had sign on door stating the sink and light did not work (use at your own risk).
• Bathroom# 2 light was not working.
• Teen Clinic had carpet with ragged edges and torn at entrance to doorway.
• Calling light #1(first light when walking in room) was not working in the Teen Clinic.
• Ceiling light #1 (first light when walking in room) was not working in Supervisor Office.
• Ceiling light (left side) in Hallway by Music Room was not working.
• Ceiling light #2 (right side) in Rap Room was not working.

11) Section 26020 Hours of Operation

The above section stales, in part, “Each program shall post the hours of operation to inform the general public and participants.”

The provider was deficient in meeting this standard because the hours of operation were not posted.