INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2023 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 four personnel records, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in all four personnel records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual training plans with an area for staff input and signature have been created by the Programs Manager and Project Director and approved by the Project Director on January 12, 2023. The Project Director and Clinical Supervisor are currently meeting with employees to map out their training for the current training period, using the new training planning form. Staff will sign off on the training plan, following a series of meetings and individual work to look for training they want and then meet again with the Project Director or Clinical Supervisor for final approval and signatures. This process will be completed for all employees by Feb. 1 and then ongoing for all new hires and then yearly, during the months of June and July. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill log for the months of September 2021 through November 2022, the facility failed to maintain a written fire drill record including documentation of any problems encountered during the fire drill and whether the fire alarm or smoke detector was operative for all fire drills reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current fire drill log did not include a column for problems encountered. The Compliance Officer changed the fire drill log to include a column for "Problems Encountered" on 1/10/2023 and submitted to the Project Director for approval. The Project Director approved the change on January 12. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility fire drill log for the months of September 2021 through November 2022, the facility failed to maintain a written fire drill record including documentation if the fire alarm or smoke detector was set off during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current fire drill log did not include a column for indicating whether or not when fire drills occur that a fire alarm is set off or some other way of executing the fire drill. The Compliance Officer changed the fire drill log to include a column for "Alarm Set Off" on 1/10/2023 and submitted to the Project Director for approval. The Project Director approved the change on January 12. The new fire drill log, with changes, will begin being used for the January fire drill. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client medical records, the facility failed to ensure that missed medication was documented in the medical records in all seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of the licensing inspection and findings with the missed dose medications not being consistently documented, the Project Director, Clinical Supervisor, and Programs Manager met with the EHR program representative to look at what options we have for documenting the various scenarios where/when our staff are not visually monitoring someone taking their medications (e.g. they take them to work with them to take). The medication system within our EHR is not editable at this time. Currently, we can document "missed" or "observed" but we cannot document "taken but not observed" (for situations such as the example given). We are currently looking at ways to document this and are working diligently with the EHR company rep to determine the best course of action. As of today, we have a couple different work around options. As of January 20, we implemented a temporary solution, as we will document the medicine in the EHR as "missed dose" and then put a notation in the comment box that the medication was taken off-site. This will be visible in the e-chart, with the note. We will finalize a method, the Project Director will approve it, and we will fully implement by Feb. 6, 2023. |