Wistar Men's R & R Program, Inc

Published
0.000
Contact Information
Licensee Name
Wistar R and R Program,Inc
9735 EmpireRoad, Qakland, CA 94603
Facility Name
Identification Number
010032EN
Reviews & Findings
Dates of Review
Juyl 13 -14, 2016
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 licensee was deficient In meeting this regulation because there are seven residents living in the facility and the program is licensed to house only six. Files were provided for Residents who were identified as currently living in the facility. However, during the course of the site visit, two additional individuals (Residents and ) were also identified living in the facility, resulting in a total of seven residents.

Deficiencies 2

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 this regulation because: 1) there is no indication that medications have ever been monitored; 2) there is no history of a medication log or Centrally Stored Medication Record; 3) the licensee’s medication policy does not allow a resident to refuse to take his prescribed medication,and 4) there is no documentation of a medication destruction record.

3. Title 9, Section 10564(e)(1) Personnel Requirements Class B

The above section states, “All personnel shall be in good health. .Except as specified in (3) below, 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. ”

The licensee was deficient in meeting this regulation because the tuberculosis test result for Employee (dated 2015) is identical to the document for 2014, with the exception of the test date being altered. Review of the personnel record could not verify that a new tuberculosis test has been administered since 2014.

The licensee was deficient in meeting this regulation because the tuberculosis test results for Employees and have expired.

The licensee was deficient in meeting this regulation because there is no documentation that a tuberculosis test has been administered to Employee.

4. Title 9, Section 10564(9) Personnel Requirements Class B

The above section states, “Residents shall not be used as substitutes for required staff but shall be permitted to participate in duties and tasks as a voluntary part of their program of activities,”

Deficiencies 3

5. Title 9, Section 10564(h) Personnel Requirement Class B

The above section states, “When regular staff members are absent, there shall be coverage by personnel capable of performing assigned tasks as evidenced by on-the-job performance, experience or training. Residents shall not be utilized to fulfill this requirement.”

The licensee was deficient in meeting this regulation because a staff member was absent on July 13, 2016, and no other staff was able to access the locked bedroom, cabinet, or garage. In addition, available staff was not able to retrieve client records until the absent staff person returned the following day.

6. Title 9, Section 10564(c) Personnel Requirements Class C

The above section states, “In addition to the requirements of (b) of this regulation, program staff who provide counseling services… shall be licensed, certified, or registered to obtain certification.”

According to Employee #3, he provides counseling services to the residents. The licensee was deficient in meeting this regulation because there was no verification of Employee #3’s counseling credentials in the personnel record.

7. Title 9, Section 10564(k) Personnel Records Class C

The above section states, “The licensee shall develop, maintain, and implement an ongoing training program for all staff in the areas identified in section 10564(b)(3) of this subchapter in addition to specific training related to their duties. Staff participation in the training program shall be documented and maintained on file for three (3) years.”

The licensee was deficient in meeting this regulation because the most recent training program provided was dated 201412015. Additionally, there was no evidence of current training in any personnel records reviewed.

Deficiencies 4

8. Title 9, Section 10564(1)(1)(2) Personnel Records Class C

The above section states, “The licensee shall maintain personnel records for all staff, including program administrators, containing: (1) Name, address, telephone number, position, duties, and date of employment; and (2) Resumes, applications, and/or transcripts documenting work experience and/or education used to meet the requirements of this regulation.”

The licensee was deficient in meeting this regulation because employment dates were not available for Employees #1 – 4.

The licensee was deficient in meeting this regulation because Employee #1, #2, and #3’s addresses and phone numbers were not contained in the personnel files.

The licensee was deficient in meeting this regulation because resumes and duty statements documenting work experience were not contained the in the personnel files for Employees #1 – 4.

The licensee was deficient in meeting this regulation because a job description was not contained in the personnel file for Employee #4.

9. Title 9, Section 10565(a) Personnel Records Class C

The above section states, “Personnel records shall be completed and maintained for each employee, shall be available to the department for review.”

The licensee was deficient in meeting this regulation because the personnel record for Employee #5 was not available for review.

10. Title 9, Section 10565(c) Personnel Records Class B

The above section states, “All records shall be maintained at the facility site. The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the department at the facility site upon request.”

The licensee was deficient in meeting this regulation because during the site visit, it was disclosed by staff that client records are maintained at Employee #5’s residence. The staff member neither resides at the residential facility or the administrative office.

Deficiencies 5

11. Title 9, Section 10566(b)(2)(A) Admission Agreements Class C

The above section states, “Admission agreements shall specify the following: Payment provisions. Amount assessed.”

The licensee was deficient in meeting the above regulation because the fees assessed for Residents and recovery or treatment services were not addressed in the written admission agreement.

12. Title 9, Section 10566(c) Admission Agreements Class C

The above section states, in part, “Such agreements shall be dated and signed by the resident and the licensee no later than seven (7) days following admission.”

The licensee was deficient in meeting this regulation because the admission agreement for Residents and were not signed or dated by the licensee.

13. Title 9, Section 10567(b) Resident Health Screening Class B

The above section states, “Every resident shall be tested for tuberculosis under licensed medical supervision within six (6) months prior to or thirty (30) days after admission and annually thereafter if continuous participation is maintained.”

The licensee was deficient in meeting this regulation because Residents and tuberculosis records were not in the files for review, and more than thirty (30} days have elapsed since admission.

14. Title 9, Section 10568(a) Resident Records Class C

The above section states, “4 separate, complete, and current record shall be maintained in the facility for each resident.”

The licensee was deficient in meeting this regulation because resident record for Residents and were not available for review.

Deficiencies 6

15. Title 9, Section 10568(b){4)(5) Resident Records Class C

The above section states, “Each record shall contain information including but not limited to the following: Date of Admission; A signed copy of the admission agreement specified in Section 10566 of this sub chapter”.

The licensee was deficient in meeting this regulation because the admission date was not documented in Resident’s record.

The licensee was deficient in meeting this regulation because the admission agreements for Residents and were not retained the in the records.

16. Title 9, Section 10572(b) Health-Related Services Class B

The above section states, in part, “During the provision of alcoholism or drug abuse recovery or treatment services a defined in section 10501(a) of this sub chapter there shall be at feast one person in the facility who is capable of providing cardiopulmonary resuscitation and first aid, not with standing section 10572(b)(1) of this sub chapter.”

The licensee was deficient in meeting this regulation because the first aid/ CPR certification for employee#4 had expired.

17. Title 9, Section 10572(d)(1)(2) Health-Related Services Class C

The above section states, “The following information shall be readily available: The name, address and telephone number of emergency agencies, including but not limited to the fire department crisis center or paramedical unit. Name and telephone number of an ambulance service.

The licensee was deficient in meeting this regulation because the aforementioned information was not readily available for the residents at the facility. It is recommended that this information be posted in a central location at the facility.

Deficiencies 7

18. Title 9, Section 10572(f} Health-Related Services Class B

The above section states, in part, “Licit medications which are permitted by the licensee shall be controlled as specified by the licensee’s written goals, objectives and procedures.”

According to the licensee’s policy and procedure manual, all licit medications are to be maintained in a locked, secure location at the residential facility. The licensee was deficient in meeting this regulation because at the time of the biennial review, the staff was not able to access the file cabinet at the facility because the key was lost.

19. Title 9, Section 10573(a)(1)(2)(4)(5)(7)(14)(17)(19) Food Service Class B

The above section states, in part:

(a) “In facilities providing meals to residents, the following shall apply:

(1) All food shall be selected, stored, prepared and served in a safe and healthful manner.

(2) Where all food is provided by the facility, arrangements shall be made so that each resident has available at least three meals per day. Not more than 15 hours shall elapse between the third meal on one day and the first meal on the following day.

(4) Between meals nourishment shall be available for all residents.

(5) Menus shall be written at least one (1) week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the residents and the department upon request.”

(7) All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

(14) All foods or beverages capable of supporting rapid and progressive growth of microorganisms which can infect or intoxicate food shall be stored in covered containers at 45 degrees Fahrenheit (7.2 degrees Celsius) or less.

(17) All kitchen, food preparation, and storage areas shall be kept clean from litter and rubbish.

(19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean, and maintained in good repair.”

Deficiencies 8

The licensee was deficient in meeting this regulation because at the time of the site inspection, cakes and pastries were observed left out in the kitchen, and not stored in a secure container. In addition, food was also being stored in the refrigerator partially wrapped in aluminum foil.

The licensee was deficient in meeting this regulation because food in the refrigerator had expired. For example, a bottle of mustard had expired on 5/14/15, and a jar of horseradish sauce expired on 8/22/14.

The licensee was deficient in meeting this regulation because the thermometer in the refrigerator shows the temperature to be 60 degrees. If the thermometer is broken, please replace it with a working one.

According to the licensee’s policy and procedure manual, the facility is to provide three meals per day to residents. The licensee was deficient in meeting this regulation because there was no indication that any meals were being served to residents.

The licensee was deficient in meeting this regulation because there was no indication that between meals nourishment is being provided by the licensee.

The licensee was deficient in meeting this regulation because menus were not available for review at the time of the biennial review.

The licensee was deficient in meeting this regulation because: 1) the refrigerator is in need of cleaning; spillage was observed in the bottom portion of the refrigerator; 2) the tile in the kitchen is damaged; 3) the baseboards in the kitchen is dirty, and 4) the stove contained grease buildup and needs to be cleaned.

20. Title 9, Section 10574 Activities Class C

The above section states, “The licensee shall demonstrate that it provides adequate opportunities for residents to participate in activities consistent with stated goals and objectives.”

The licensee was deficient in meeting this regulation because group counseling sessions were scheduled Monday – Friday from 10:00 a.m. to 12:00 p.m. According to staff, all residents work weekdays during these hours, and therefore, are not able to attend.

Deficiencies 9

21. Title 9, Section 10581(a) Buildings and Grounds Class C

The above section states, “Facilities shall be clean, safe, and sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.”

The licensee was deficient in meeting this regulation because:

• Fire alarm was beeping, indicating the battery was in need of replacement.
• Light fixture in bedroom #3 is hanging on a wire, and not firmly attached to the ceiling.
• Furniture in the living room is soiled / ripped and is in need of cleaning / replacement.
• Couch located in the side yard is dirty and should be discarded.
• Paint both inside and outside of the facility is chipped / dirty and requires repainting.
• Exterior siding of the house contains holes and needs replacement.
• Ceiling shows signs of water damage.
• Filter of the heating unit needs to be cleaned.

22. Title 9, Section 10584(b) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, “All window screens shall be in good repair and free of insects, dirt and other debris.”

The licensee was deficient in meeting this regulation because the window screen in bedroom #2 is bent.

The licensee was deficient in meeting this regulation because the windowsill in bedroom #3 is dirty and needs to be cleaned.

23. Title 9, Section 10584(e) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, ”All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating conditions.”

The licensee was deficient in meeting this regulation because the sink in the restroom contains a hole and needs to be fixed or replaced.

The licensee was deficient in meeting this regulation because the faucet in the restroom is leaking.

24. Title 9, Section 10584(9) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, “The licensee shall provide clean linen in good repair, including lightweight, warm blankets, top and bottom bed sheets, pillow cases, mattress pads, bath towels, and wash cloths.”

The licensee was deficient in meeting this regulation because the flat sheet is missing on a bed in bedroom #2.

The licensee was deficient in meeting this regulation because mattress pads are not provided for any of the beds in the facility.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 6
Census: 6

TREATMENT CAPACITY:
Approved: 6
Census: 5