West Oakland Health Council

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Contact Information
Licensee Name
The West Oakland Health Council
700AdelineStree, Oakland, CA 94607
Facility Name
Identification Number
010005JN
Reviews & Findings
Dates of Review
27-Sep-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1. Section 12010(b) Admission and Readmission Criteria and Procedures

The above section states, “The program shall have written admission and readmission criteria for determining the participant’s eligibility and suitability for services and procedures, which shall be available to the applicant and the general public.”

The provider was deficient in meeting this standard because a written document, describing the readmission criteria, was not found in the policy and procedure manual.

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

2. Section 12015(a) Intake

The above section states, in part, “If a participant is appropriate for treatment, the following information shall be gathered: Social, economic and family history; previous treatment”

The provider was deficient in meeting this standard because social, economic and family history information was not gathered for participants.
.

The provider was deficient in meeting this standard because the treatment for participants was not documented in the participant file.

Deficiencies 2

3. 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 participant’s files.”

The provider was deficient in meeting this standard because documentation of drug screening results was not contained in the participant files for participants.

4. Section 12055 Referral Arrangements

The above section states, “If during the course of recovery or treatment services the participant is assessed and determined to be in need of additional services, the program shall provide the participant with a referral to the appropriate services; if available. The program shall maintain and make available to participants a current list of resources within the community that offer services that are not provided within the program. At a minimum, the list of resources shall include medical, dental, mental health, public health, social services and where to apply for the determination of eligibility for Stat e, federal, or county entitlement programs.”

The provider was deficient in meeting this standard because referral arrangements do not include medical, dental, mental health, public health, and where to apply for determination of eligibility for State federal or county entitlement programs.

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

5. 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; (3) Action steps that will be taken by program and/or participant to accomplish the identified objectives; and (4) Target date(s) for accomplishment of action steps and objectives.”

The provider was deficient In meeting this standard because all treatment plans provided for participant from through have been identical. There has been no documentation to show whether or not any progress has been achieved or whether or not objectives have been met.

Deficiencies 3

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

The above section states, The process for participant recovery 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 participant’s admission.

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

The participant signed the admission agreement on and a treatment plan had not been developed.

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

The above section states, in part, “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 this standard because the treatment plan had not been reviewed by staff and participant.

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 file. 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 the above standard because participant attended group sessions, however, progress was not document for any of these cares.

.The provider was deficient in meeting this standard because the counselor did not sign their name on the progress notes for individual sessions conducted on participant.

Deficiencies 4

9. Section 13000(e)(2)(A) Individual and Group Sessions

The above section states, in part, “Outpatient: A minimum of two individual or group sessions shall be provided for each participant per 30-day period or more often, depending on the participant’s need and recovery or treatment plan.”

The provider was deficient in meeting this standard because participant had not attended any individual or group sessions.

10. 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 this standard because a copy of the consent to follow-up was not contained in the participant files for participants.

11. Section 18000 Board of Directors and Community Advisory Board

The above section states, in part, “All boards addressed in Sections 18000, 18005, and 18010 shall include persons who are knowledgeable about alcohol and/or-other drug recovery and treatment, and representative of the community served. The names and addresses of all the board of directors and community advisory
board members shall be available.

The provider was deficient in meeting this standard because the names and addresses of all the board of directors and community advisory board members were not available for review.

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

Deficiencies 5

12. Section 19005(b) Personnel Policies

The above section states, in part, “The program shall ma;maintain personnel files on all employees. Each personnel file shall contain: (5) Employee evaluations; and (6) Health records including a health screening report or health questionnaire,and tuberculosis test results as required.”

The provider was deficient in meeting this standard because an employee evaluation had not been provided for Employee #2 since January 8, 2014.

The provider was deficient in meeting this standard because health records were not contained in the personnel files for Employee.

The provider was deficient in meeting this standard because Employee did not have current tuberculosis test results on file.

13. Section 19010(b) Code of Conduct

The above section states, “The code of conduct shall include the program policies regarding at a minimum the following: (6) Conflict of interest; and (7) Confidentiality.”

The provider was deficient in meeting this standard because conflict of interest documentation was not contained in the personnel files for Employees number #1, #2, and #3.

The provider was deficient in meeting this standard because confidentiality documentation was not contained in the personnel file for Employee #2.

14. 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 the program shall pace the signed copy in the personnel file of the individual.”

The provider was deficient in meeting this standard because a signed copy of the code of conduct was not contained in the personnel record for Employees #2 and #3.

15. Section 19020(a) Staff Training

The above section states, “The program shall have a 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 employees.

Deficiencies 6

16. 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 an admission agreement was missing in the participant file for Participant

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

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.

The provider was deficient in meeting this standard because the process for filing a grievance does not include contact information for the Department of Health Care Services.

18. Title 9, Section 10564(c) Personnel Requirements

The above section states, “In addition to the requirements of (b) of this regulation, program staff who provide counseling services (as defined in Section 13005) shall be licensed, certified, or registered to obtain certification pursuant to Chapter 8 (commencing with Section 13000).”

The provider was deficient in meeting this regulation because Employee #3 was hired to provide counseling services, yet the counselor is not registered, certified or registered.

Detailed Information
Census Data

OUTPATIENT