Sunrise Community Counseling Center

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Published
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Contact Information
Licensee Name
Sunrise Community Counseling Center
537 South Alvarado Street, Los Angeles, CA 90057
Facility Name
Identification Number
190110CN
Reviews & Findings
Dates of Review
23-Jun-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 12040 Medication

The above section states, “All alcohol and/or other drug programs shall have a written policy statement regarding the use of prescribed medications by program participants. Such a policy shall not necessarily preclude the licit use of prescribed medications.”

The provider was deficient in meeting the standard because there was no policies or procedures on using prescribed medicaitons by participants.

2) Section 12080 Continuing Recovery or Treatment Exit Plan

The above section states in part , “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.”

The provider was deficient in meeting the standard because there was no policy procedures continuing recovery and or treatment exit planning.

3) Section 12085 (3)(4) Discharge Summary

The above section states, “Each program shall have written procedures regarding participant discharge. These procedures shall contain the following; (3) Vocational and educational achievements; (4) Legal status.

The provider was deficient in meeting the standards because the above information was missing from the discharge policies.

4) Section 17010 (8-13){16-17)(19-22) Program Policies

The above section states, in part, “All program policies and procedures shall be contained in an operation manual that is located at each certified site and that shall be available. The policies and procedures manual shall contain (8) Detoxification services, if applicable; (9) Program administration; (10) Personnel practices; (11) Participant grievances/complaints; (12) Fiscal practices; (13) Continuous quality management; (16) Confidentiality; (17) Community relations; (19) Use of prescribed medications by participants; (20) Maintenance and disposal of participant files; (21) Drug screening; and (22) Code of conduct.”

The provider was deficient in meeting the standards because above information was missing from the program policies.

5) Section 17015 (c)(d)(1-3)(e) Participant Files

The above section states, in part “(c) All participant files shall be maintained and information released in accordance with Title 42, Code of Federal Regulations Part 2; (d) Other requirements, (1) The documents in the participant file shall be written legibly in ink or typewritten. If program files are computerized, they shall be accessible to the Department’s staff for review. (2) All entries shall be signed and dated. (3) All significant information pertaining to a participant shall be included in the participant file.”

The provider was deficient in meeting the standards because above information was missing from the policies and procedures manual.

6) Section 17020 (a)(b)(c) Continuous Quality Management

The above section states, in part, “Each program shall maintain written policies and procedures for continuous quality management and shall document in participant file compliance with the procedures. The procedures shall include the following:(a) Continuity of Activities (b) Participant File Review (c) Recovery or Treatment Plan-Review.”

7) Section 19005 (a)(1-4)(A-F) Personnel Policies

The above section states, “(a) The-program shall establish and maintain personnel policies that: (1) Are written and revised as needed and are approved by the governing body; (2) Are applicable to all employees and are available to and reviewed with new employees; (3) Comply with applicable local, state and federal employment practice was and (4) Contain information (A) Recruitment hiring process, evaluation, promotion, disciplinary action.and termination; (B) Equal employment opportunity, nondiscrimination and sexual harassment policies as applicable; (C) Employee benefits, (vacation,sick leave, etc.), training and development and grievance procedures; (D)Salary schedules, merit adjustments, severance pay and employee rules of conduct; (E) Employee safety and injuries; and (F) Physical health status including a health screening report or health questionnaire, and tuberculosis test results”.

The provider was deficient in meeting the standard because the above information was missing from the policies and procedures manual.

8) Section 19015 (a)(b) Health Screening and Tuberculosis Requirements

The above section states, in part, “(a) All staff and volunteers whose functions require or necessitate contact with participants shall complete a health screening report or a health questionnaire; (b) All staff and volunteers whose functions require or necessitate contact with participants shall be tested for tuberculosis”.

The provider was deficient in meeting the standard because the above information was missing from the policy and procedure manual.

9) Section 19020 Staff Training

The above section states, “The program shall foster and encourage the continuing development of staff expertise and staff attendance at appropriate training programs.”

The provider was deficient in meeting the standard because there was not policy or procedure on staff training.

10) Section 20000(a) Fiscal Practices

The above section states, “(a) All programs shall have a written policy for the assessment and collection of fees.”

The provider was deficient in meeting the standard because there was no policy or procedure on assessment and of collection of fees.

11) Section 21000(a)(b) Admission Agreement

The above section states, in part, “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.

a) Fees assessed for services provided; (b) Activities expected of participants;”

The provider was deficient in meeting the standards because the above information was missing from the policy and procedures manual.

12) Section 22000 (a)(1-7) Participants Rights

The above section states, in part, “(a) Each participant shall have rights that include, but are not limited to, the following; (1)The right to confidentiality; (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/he 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 the standards because the above information was missing from the policies and procedures.

13) Section 22000 (b)(c)(d) Participants Rights

The above section states, in part, “(b) Each participant shall review, sign, and be provided at admission, a copy of the participant rights … The program shall place the original signed participant rights document in the participant’s file; (c) The provider shall post a copy of the participant rights in a location visible to all participants and the general public. (d) The follow-up after discharge can not occur without a written consent from the participant.”

The provider was deficient in meeting the standards because the above participant’s rights was missing from the policy and procedure manual.

13) Section 25000 Community Relations

The above section slates, in part “A written description of the program’s services and admission criteria and procedures shall be provided to the applicants … to cooperating referral sources that may include emergency room personnel, law enforcement agencies, and self-help groups such as Alcoholics Anonymous. Continuing efforts shall be made to guarantee coordination and cooperation with other service providers and enhance relations.”

The provider was deficient in meeting the standards because the above information was missing from the policy and procedure manual.

14) Section 26010 (a)(b)(c)(d) Health and Safety

The above section states, “(a) Programs shall be clean, safe, sanitary and in good repair at all times for the safety and well being of participants, employees and visitors; (b) All participants shall be protected against hazards within the program through provision of protective devices including but not limited to nonslip material on rugs; (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction and lighted for the visibility and safety of all participants; (d) Program equipment and supplies shall be stored in appropriate space and shall not be stored in space designated for other activities.”

The provider was deficient in meeting the standards because the above information was missing from the policy and procedure manual.