INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25-26, 2024, 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(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.
Staff #5 was hired as a Clinical Technician on September 9, 2021, and was still in the position as of the date of the inspection. Staff #5 and was due to have the TB/STD trainings no later than September 9, 2023. There was no documentation in the personnel file of the completion of this training.
Staff #6 was hired as a Financial Coordinator on April 11, 2022, and was still in the position as of the date of the inspection. Staff #5 and was due to have the communicable disease trainings no later than April 11, 2024, There was no documentation in the personnel file of the completion of the TB/STD or HIV/AIDS trainings.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Prior to this licensing inspection visit, our facility had no system in place to track that the minimum six hours of HIV/AIDS training and the minimum four hours of TB/STD training was getting completed in required time frame.
Following the licensing visit, the Project Director, Compliance Officer, and Staff Development Officer met to discuss a quality plan to address this issue. As a result of that meeting, the following will be put into place:
1. Staff member number 5 registered for the missing TB/STD training for February 4, 2025.
2. Staff member 6 completed both the HIV/AIDS & TB/STD training in October and November of 2024.
3. Our hiring form will be revised to include a statement that indicates time frames for completion of the aforementioned trainings on the orientation checklist form, by December 10, 2024.
4. The training plan is being changed to add a section for due date of the mandatory trainings (HIV/AIDS & TB/STD), according to date of hire and position, by December 12, 2024.
5. A memo is being sent out to all current staff with their required due dates for the HIV/AIDS & TB/STD trainings, by 12/13/2024.
6. The Staffing Compliance Policy and Procedures will be updated to include a statement regarding the mandatory HIV/AIDS & TB/STD trainings, by 12/23/2024. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Staff #3 was hired on January 17, 2024, as a counselor assistant and was still in the position as of the date of the inspection. The training was completed on January 26, 2024.
Staff #4 was hired on June 24, 2024, as a counselor assistant and was still in the position as of the date of the inspection. The training was completed on July 21, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to correct this deficiency, the Project Director, Compliance Officer, and Staff Development Officer met to discuss ways that we can ensure all newly hired staff get the mandatory fire extinguisher training in their first week of employment. As a result of the findings on this licensing audit, and our internal staff meeting, the following are being/will be put in place and completed by Friday, December 20, 2024.
1. The new hire orientation checklist will be updated to put a due date for the fire extinguisher training to be taken on day 2 of their employment, by December 10, 2024.
2. The recorded training video and pre-post test will be put on the Phoenix Domus internal portal site, on our newly developed staff training page, by December 17, 2024.
3. The Staffing Compliance Policy and Procedures will be updated to include details about the requirement for the fire extinguisher training to be completed on day two of their employment with Phoenix Domus, by December 20, 2024. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Staff #3 was hired on January 17, 2024, as a counselor assistant and was still in the position as of the date of the inspection. The training was completed on January 26, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to correct this deficiency, the Project Director, Compliance Officer, and Staff Development Officer met to discuss ways that we can ensure all newly hired staff get the mandatory Emergency & Safety Training in their first week of employment. As a result of the findings on this licensing audit, and our internal staff meeting, the following are being/will be put in place and completed by Friday, December 20, 2024.
1. The new hire orientation checklist will be updated to put a due date for the Emergency & Safety Training to be taken on day 3 of their employment, by December 10, 2024.
2. The Staffing Compliance Policy and Procedures will be updated to include details about the requirement for the fire extinguisher training to be completed on day 3 of their employment with Phoenix Domus, by December 20, 2024.
3. The Compliance Officer will record a training video going over the Emergency & Safety Policies/Procedures, to include a video of the emergency safety signs/exits, how to manually do a fire drill, where the manual pull fire alarms are located/how to use them, and where the fire extinguishers are located on both levels of the facility, by January 8, 2025.
4. The Compliance Officer will develop a pre/post-test for the Emergency & Safety Training by January 10, 2025.
5. The Compliance Officer will add the training video and the pre/post-test to the Phoenix Domus internal staff portal site, by January 14, 2025. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in seven out of seven client records reviewed.
Client #1 was admitted on June 14, 2024, and was still active at the time of the inspection. Two consents, both dated June 14, 2024, for an emergency contact and a payor, did not include documentation that a copy was offered to the client.
Client #2 was admitted on July 17, 2024, and was still active at the time of the inspection. Two consents, both dated July 17, 2024, for a healthcare provider and an emergency contact, did not include documentation that a copy was offered to the client.
Client #3 was admitted on May 15, 2024, and was still active at the time of the inspection. Three consents, all dated May 15, 2024, for a healthcare provider, payor and an emergency contact, did not include documentation that a copy was offered to the client.
Client #4 was admitted on February 27, 2024, and discharged on June 7, 2024. Two consents, both dated February 27, 2024, for a healthcare provider and a payor, did not include documentation that a copy was offered to the client.
Client #5 was admitted on March 4, 2024, and discharged on July 16, 2024. Two consents, both dated March 4, 2024, for an emergency contact and a payor, did not include documentation that a copy was offered to the client.
Client #6 was admitted on June 20, 2024, and discharged on October 5, 2024. Two consents, both dated June 20, 2024, for a healthcare provider and a payor, did not include documentation that a copy was offered to the client.
Client #7 was admitted on April 13, 2024, and discharged on September 15, 2024. A consent, dated April 13, 2024, for a payor did not include documentation that a copy was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
At the time of our November 25 and 26 licensing inspection, our 5 Point Limited ROI did not have an area to indicate that the ROI was offered to the resident. The following have been/are being implemented to address this issue.
1. The Compliance Officer worked with our EHR support team to revise our current form to include areas to indicate that the ROI was offered to the client, as well as a dropdown menu to select whether the client accepted or refused a copy of the ROI. This form was revised and placed in our EHR on December 12 by the Compliance Officer.
2. A memo will be sent out to all counseling and intake staff, notifying them of the change in the ROI form and how it is mandatory to offer a copy of the ROI to the resident when an ROI is filled out and signed. This memo will be sent by the Project Director by Wednesday, December 18.
3. The intake coordinator is going to meet with all current residents (to include Client #1, Client #2, Client #3) to fill out new ROIs (to replace the version that does not have the indicators for offering a copy of the ROI to the client), have them sign, indicate whether they want copies by documenting on the new form accordingly. This will be completed by December 20, 2024.
4. The old ROI without the indicator for a copy being offered to the client will be deleted from our system and the new form will be added to the current intake encounter by the Compliance Officer by December 20, 2024.
5. The Project Director will review all records of current clients to ensure the new ROI form has been updated to replace the old version, by December 24, 2024. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary, in two out of four applicable records reviewed. The facility's policy is to complete a discharge summary on the date of the client's discharge.
Client #6 was admitted on June 20, 2024, and was discharged on October 5. 2024. A discharge summary was completed on November 14, 2024.
Client #7 was admitted on April 13, 2024, and was discharged pm September 15, 2024. There was no documented discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of the review of client records and findings related to this deficiency, the Project Director, Lead Counselor, and Compliance Officer met to discuss a formal plan to correct the deficiency.
To note, both client #6 and client #7 left the facility Against Medical Advice (AMA). When the Project Director met with the counseling staff to determine how/why client #6 had a discharge summary completed 40 days after he left the facility AMA, and client #7 had no discharge summary completed after he left the facility AMA.
Further research and discussion yielded that our current Discharge and Aftercare Follow-Up Policy and Procedure had no specific details as to what documentation must be completed when a client leaves the facility AMA.
The following have been/are being implemented to put a formal system in place to address the area of concern.
1. The Discharge and Aftercare/Follow-up Policy and Procedure was revised and approved by the Project Director on Friday, December 13, 2024 to include the statement:
"AMA Discharge
In the event someone leaves the program Against Medical Advice (AMA), the counselor (or Project Director or Lead Counselor) must make the mandatory phone call to the resident's Emergency Contact as close to the time when the resident leaves AMA as possible, but no more than 12 HOURS OF THE RESIDENT LEAVING AMA. If the person leaving AMA revokes his Emergency Contact ROI, no phone call will be made to the emergency contact by the counselor.
In addition to, and following the E.C. phone call, the counselor will complete the "ASAM Discharge Summary" housed in our EHR. The form must be fully completed and signed within 24 hours of the resident leaving the facility AMA. If the resident who left AMA is not available to sign the ASAM Discharge Summary, the counselor completing the form will note that the resident is not available for signature, with a reason given. In all cases, the staff completing the AMA Discharge Summary must be signed by the staff member WITHIN 24 HOURS OF THE RESIDENT LEAVING AMA.
The counselor or other on-duty staff must notify the Project Director to provide details about the AMA. The Project Director will notify the resident's care manager, and the Compliance Officer will complete any necessary incident reports (e.g. CCBH Significant Member Incident [SMI]) report, according to the oversight entity's timeframe guidelines.
It is imperative that the follow-up contact within 30 days must happen for any resident who discharges AMA. The follow-up can be a phone call, email, or letter sent."
2. A memo is being sent out by the Project Director to all counseling staff that the Discharge & Aftercare/Follow-up Policy has changed and detailing how the AMA discharges ought to be handled, by Monday, December 16.
3. The Compliance Officer will monitor the discharge paperwork for all residents who discharge on a monthly basis, beginning December 2024 and ongoing. When issues/problems are identified, the Compliance Officer will notify the Project Director for immediate intervention with all counseling staff.
4. Counseling staff will be notified about the change by the Project Director and Compliance Officer during the next all-staff meeting, being held on Tuesday, January 7, 2025.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information, in two out of four applicable records reviewed. The facility's policy is to complete a follow-up contact within thirty days of discharge.
Client #5 was admitted on March 4, 2024, and was discharged on July 16, 2024. There was no documentation of a follow-up contact in the client record.
Client #7 was admitted on April 13, 2024, and was discharged on September 15, 2024. There was no documentation of a follow-up contact in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of the findings related to staff following up with discharged clients within 30 days of them leaving the program, the Project Director, Lead Counselor, and Compliance Officer met to discuss why we fell short in this area. What we found was that follow-up contacts are being made, but they have not been consistently documented in the client's chart. In order to rectify this citation, the following plan is being put in place (which began on December 2, 2024 and will be completed by January 7, 2025). The Project Director and Clinical Supervisor will monitor the discharge contacts on a monthly basis and report to the Compliance Officer the results each month.
1. The Project Director is going to send out a memo alerting counseling staff of the need to make a contact with residents within 30 days of them leaving the program (this includes: successful completions; AMA discharges; transfers). The PD will also emphasize the need to enter a note in Patient Communication that the contact was made (or attempted). This task will be completed by December 18, 2024.
2. The Compliance Officer will develop a discharge report in our EHR that will show the last 30 days of all discharges. The report will be run every week by either the Project Director or Lead Counselor. The report will then be distributed to the counseling staff. The creation of the report will be completed by January 3, 2025.
3. The Project Director will discuss the change in how the follow-up contacts are conducted at the next all-staff meeting, to be held on January 7, 2025.
4. Contacts will be made by the counseling staff to client #5 and client #7 and documented as a "late entry" in the Patient Communications in the EHR. |