INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11-12, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Phoenix Domus LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to develop a written individual training plan for each employee in two of four records. The facility ' s policy and procedures state that all training plans must be completed by the employee, returned to the Project Director, and approved prior to July 1. New employees develop a plan during orientation that lasts until beginning of next training year.The current training year is July 1, 2025-June 30, 2026.Staff #1 was hired as the project director on January 1, 2021, and was still employed at the time of inspection. The 2025-2026 training plan was due no later than July 1, 2025; however, there was no training plan in the record.Staff #2 was promoted to lead counselor on May1, 2024, and was still employed at the time of inspection. The 2025-2026 training plan was due no later than July 1, 2025; however, it was completed on July 7, 2025.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Correction of Specific Deficiencies
Staff #1 (Project Director): A comprehensive 2025?2026 Individual Training Plan has been developed, reviewed, and placed in the personnel record. This plan includes 15 hours of training, which exceeds the 12 hours mandated for the Project Director position.
Staff #2 (Lead Counselor): The personnel record for Staff #2 has been reviewed to ensure the July 7, 2025, training plan is signed and compliant with the facility's current curriculum.
Completion Date: Immediately (Completed by January 5, 2026).
2. Identification of Other Potentially Affected Records
Audit of Personnel Files: The Compliance Officer will conduct a 100% audit of all current personnel files (including Clinical Technicians and the Nurse Care Coordinator) to ensure every employee has an active 2025?2026 training plan on file that was approved by the July 1 deadline.
Orientation Check: For employees hired after July 1, 2025, records will be reviewed to confirm a plan was developed during orientation to last until the start of the next training year.
Responsible Staff: Compliance Officer.
Completion Date: January 10, 2026.
3. Systemic Changes to Prevent Recurrence
New Tracking Matrix: A Staff Development Tracking Log has been created and will be implemented. This matrix lists hire dates, promotion dates, and the specific due date for the annual ITP (July 1st).
Internal Deadline Policy: To prevent late submissions (as seen with Staff #2), Phoenix Domus will now require all draft ITPs to be submitted to supervisors by June 15th of each year to allow for a 15-day review and signature period.
Supervisor Training: All supervisors will be retrained on the new protocol. Supervisors are now strictly responsible for ensuring their direct reports have signed plans prior to the July 1st cutoff.
Responsible Staff: Project Director and Lead Counselor.
Implementation Date: January 15, 2026 (Ongoing for the 2026-2027 cycle). |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe in two of six records.Staff #5 was hired as a Clinical Technician on August 26, 2023, and was still in the position at the time of the inspection. Staff #5 was due to have the TB/STD training no later than August 26, 2025; however, the training was not completed. Staff #6 was hired as a Care Coordinator on November 2, 2023, and was still in the position at the time of the inspection. Staff #6 was due to have the communicable disease trainings no later than November 2, 2025; however, HIV/AIDS was completed November 25, 2025, and TB/STD was completed November 26, 2025. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the November 25-26, 2024, annual licensing inspection.
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Plan of Correction
1. Immediate Correction of Specific Deficiencies
Staff #5 (Clinical Technician): The employee has been registered for the next available in-house or external TB/STD training module to satisfy the 4-hour requirement.
Staff #6 (Care Coordinator): Although completed late, the personnel file has been updated with the certificates for HIV/AIDS (6 hours) and TB/STD (4 hours) to verify current compliance.
Completion Date: January 10, 2026.
2. Systemic Change: Implementation of In-House Training
To eliminate reliance on external wait-lists and ensure 100% compliance with regulatory deadlines, Phoenix Domus will move to an Internal Training Model.
Internal Curriculum Approval: The Compliance Officer will utilize the Department of Health (DOH) approved curriculum outlines (referenced in Licensing Alert 6-97 for TB/STD and Licensing Alert 02-2023 for HIV/AIDS) to develop and deliver in-house training.
Training Frequency: The Compliance Officer or Nurse Care Coordinator will facilitate these mandatory trainings bi-annual (two times per year) (or as needed for new hires) to ensure all staff meet their 1-year (counselors) or 2-year (all other staff) deadlines.
Regulatory Compliance: Per DOH guidelines, in-house curricula do not need prior submission to the Department but will be maintained on-site for review during inspections.
Completion Date: February 28, 2026 (ongoing thereafter).
3. Quality Improvement & Monitoring
Tracking Matrix: The Compliance Officer will implement a Mandatory Training Master Log that tracks the hire date of every employee and triggers a "6-month warning" for any staff member who has not yet completed their communicable disease requirements.
HR Orientation Update: The new hire orientation checklist has been amended to include a tentative date for the staff member's in-house HIV/AIDS and TB/STD training within their first 90 days of employment.
Responsible Staff: Compliance Officer.
Completion Date: January 15, 2026.
4. Evidence of On-Going Compliance
Bi-Annual Audits: The Project Director will conduct a bi-annual audit of personnel records to ensure all training certificates are present and that training was received within the mandated timeframe.
Documentation: Phoenix Domus will maintain training sign-in sheets, agendas, quiz results, and certificates for all in-house sessions for verification by licensing staff. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.The fire drills were reviewed for the period of November 2024-November 2025. The only fire drills conducted during sleeping hours in that timeframe were documented on December 2024, and October 2025. This period is longer than the required 6 months. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Immediate Correction of Specific Deficiencies
Documentation Review: The fire drill logs for the period of November 2024 to November 2025 were reviewed, confirming the gap between the December 2024 and October 2025 overnight drills exceeded the six-month requirement.
Corrective Drill: An overnight fire drill was successfully conducted and documented to establish a new compliance baseline.
Completion Date: December 30, 2025.
2. Systemic Changes to Prevent Recurrence
To ensure consistent adherence to the six-month "sleeping hours" requirement, Phoenix Domus is implementing a digital scheduling and alert system:
Master Fire Safety Calendar: The Project Director will develop a permanent annual calendar specifically for fire drills (including highlighting overnight fire drills). This calendar will clearly marks the "Must Complete By" dates for each six-month cycle (e.g., January and July).
Staff Portal Integration: This calendar will be hosted on the Phoenix Domus Staff Portal, providing transparent access to the schedule for all employees.
Automated Alert System: The calendar is configured to send automated alerts to all staff 24 hours prior to the scheduled deadline for the overnight fire drill. This ensures that the on-shift Clinical Technicians are aware of the requirement and prepared to execute the drill.
Responsible Staff: Project Director and Compliance Officer.
Implementation Date: January 10, 2026.
3. Quality Improvement & Monitoring
Monthly Safety Review: During the first week of every month, the Project Director will audit the fire drill log to verify that any drills due within that month are scheduled or completed.
Quarterly Compliance Checks: The Compliance Officer will review the fire drill log quarterly to ensure compliance with state standards and internal accountability.
Staff Training: All overnight Clinical Technicians will receive refresher training on how to properly conduct and document overnight drills in the facility log to ensure that the time of the drill clearly reflects "sleeping hours."
Responsible Staff: Project Director and Compliance Officer.
Completion Date: January 20, 2026 (Ongoing). |