1) Section 17015(b)(3)(I) Participant Files
The above section states, in part, “At a minimum, each participant file shall contain the following: (3) Other Data: (I) Consent to follow-up.”
The provider was deficient in meeting the above standard because the consent to follow up was missing or not signed for all participants reviewed.
2) Section 19005(b)(5)(7) Personnel Policies
The above section states, in part, “The program shall maintain personnel files for all employees. Each personnel file shall contain:
(5) employee evaluations and (7) other personnel action.”
The provider was deficient in meeting the above standard because of the following:
• Missing a signed copy of conflict of interest, code of conduct, and confidentiality for employees 4 and 5.
• Missing evaluation for employees 1 and 3.
3) Section 2601O(a) Health Screening and Tuberculosis Requirements
The above section stales, “Programs shall be clean, safe, sanitary and in good repair at all limes for the safety and well being of participants, employees and visitors.”
The provider was deficient in meeting the above standard because of the following:
• Baseboard damage in counselor/group room
• Exposed wires in group room 5
• Cable cord attached to ceiling hanging down to the ground/tripping hazard in group room 5
• Holes (2) in the wall of counselor office 3
• Water line duct taped to wall or not secured in men’s bathroom 1
• Hole in wall of laundry room
TOTAL OCCUPANCY:
Approved: 34
Census: 21
TREATMENT CAPACITY:
Approved: 34
Census: 21