Tahoe Youth and Family Services

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Published
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Contact Information
Licensee Name
TAHOE YOUTH AND FAMILY SERVICES
1021Fremont Avenue, South Lake Tahoe, CA 96150-8136
Facility Name
Identification Number
090006AN
Reviews & Findings
Dates of Review
21-Jun-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

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

The above section states, In part,
(b) The process for participant recovery or treatment plans shall be the following:
(4) If a treatment plan is developed:
(A) Staff shall develop the initial treatment plan with input from the participant In accordance with the time frame below:
(3) For non residential programs the treatment plan shall be developed within 30 days from the date of the participant’s
admission.

The provider was deficient In meeting the above standard because the initial treatment plan was:
* Developed on 49 days after admission for participant.
* Developed on 43 days after admission for participant.
* Developed on 93 days after admission for participant.

Deficiencies 2

2) Section 12070(b)(4)(C) Recovery or Treatment Planning

The above section states, in part,
(c) Staff and the participant shall review and update the treatment plan when a change in problem identification or focus of recovery
or treatment occurs, or no later than 90 days after signing the initial treatment plan and no later than every 90 days thereafter,
whichever comes first.”

The provider was deficient in meeting the above standard because ah updated treatment plan was due no later than however the update was completed for participant

3) Section 12080 Continuing Recovery or Treatment Exit Plan

The above section states, “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 goofs Identified in the recovery or treatment plan and shall include referrals to appropriate resources (e.g., social services, Medical and
vocational/rehabilitation, and others).”

The provider was deficient in meeting the above standard because a continuing recovery exit plan was not in the participant’s file, for participant.

4) Section 12085(b)(6) Discharge Summary

The above section states, in part,
(b) A discharge summary that Includes:
(6) Participant’s continuing recovery or treatment exit plan;

The provider was deficient in meeting the above standard because: Refer to Deficiency #3.

5) Section 17015(d)(2) Participant Files

The above section states, in part,
(d) Other requirements
(2) All entries shall be signed and dated.

The provider was deficient in meeting the above standard because the updated treatment plan was not dated
by the participant, for participant.

6) Section 17020(a)(1) Continuous Quality Management

The above section states, in part,
(a) Continuity of Activities
(1) A recovery or treatment plan rs developed within the time frame specified in Section 12070
b.3.A. or Section 12070 b.4.A. of these Standards.

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

7) Section 17020(a)(5) Continuous Quality Management

The above section states, in part,
(a) Continuity of Activities
(5) The recovery or treatment plan is reviewed by the participant and updated as necessary at least every 90 days.

The provider was deficient in meeting the above standard because an updated treatment plan that was due by (90 days after admission)was completed for participant.

8) Section 19005{b)(5) Personnel Policies

The above section states, In part,
(b) The program shall maintain personnel fifes on all employees. Each personnel file shall contain:
(5) Employee evaluations;

The provider was deficient in meeting this standard because an annual employee evaluation was missing from the employee fire:
– For employee#2 (the last evaluation was conducted on May 7. 2015}.
– For employee #4 (the last evaluation was conducted on May 26, 2015).
– For employee #5 {no evaluation).

9) Section 19010(c) Code of Conduct

The above section states, in part,
(c) The program shaft post the written code of conduct In a public area that is available to participants.

The provider was deficient in meeting the above standard because a copy of the employee code of conduct was not posted in a public area.

10) Section 22000(a)(7) Participant Rights

The above section states, in part,
(a) Each participant shall have rights that include, but are not limited to, the following
(7) To be accorded access to his or her fife.

The provider was deficient in meeting the above standard because the document used for admission to the program, i.e. Participant Rights and Services Contract, did not include the participant’s right to access their file.