INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8-9, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor was qualified for their position at the time of hire in one of one applicable records reviewed.
Staff #3 was hired on August 7, 2023 and still a current employee. Staff #3 does not have a qualifying degree from an accredited college.
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, staff number three was demoted to the role of counselor assistant until he can fulfill all requirements that the state asks for of counselors. He will receive weekly supervision from the clinical supervisor. He will be evaluated in 6 months to determine whether he is on track to become a full counselor.
As a result of this deficiency, and in a quest to ensure our hiring practices meet the needs of all the various oversight entities, the Compliance Officer worked with the Project Director and Clinical supervisor to add quality steps to the hiring process. When we have an opening for a counselor position, the Clinical Supervisor will complete a personnel requisition form and send it to the Project Director and Compliance Officer. This form has been created and revised recently on 12/3/2023 to include statements and signature areas for: the Clinical Supervisor; the Compliance Officer; and the Project Director. Following the personnel requisition form submission, the Compliance Officer will post the job, with specific qualifications to ensure the candidates understand the qualifications. The Clinical Supervisor will review resumes and send them to the Compliance Officer for review of qualifications (degree and experience). The Compliance Officer will then confirm with the Project Director, who will give the final say on a candidates qualifications. Once all three signatures on on the Personnel Requisition Form, the form will be returned to the Clinical Supervisor, and interviews will be set up. Prior to the offer being made, the Clinical Supervisor and/or Project Director will check references. A memo will be sent out by December 12, 2023 to all staff indicating this change. As well, an addendum to the hiring policy/procedure will be made to detail the steps provided here, by January 1, 2024. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to ensure each staff member completed a mechanism to collect feedback on completed trainings in one of three applicable records reviewed.
Staff #4 was hired on September 27, 2021 and still a current employee. No feedback forms were documented on any trainings completed during the 2022 to 2023 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff number 4 completed all training hour requirements, mostly by completing online courses. During employee evaluation time, this employee stated that she completed evaluations for the online courses but did not print out any documentation of the training evaluation. The Compliance Officer met with the Clinical Supervisor and Project Director to enact a plan to make sure that all feedback forms are collected following all training (both internal and external training) and immediately put in the employee's file. The Clinical Supervisor will hold a meeting in January of each year to discuss training completed for the current training year period and ask employees to bring all training documentation to that meeting. This adds a mid-point check, instead of waiting until the employee evaluation process in June of each year. The Compliance Officer asked the Clinical Supervisor to discuss this change at the next all-staff meeting (January 8, 2024). As well, the Compliance Officer will send out a memo alerting all staff of the importance of collecting the training feedback forms for all training completed, no exceptions. This memo will be sent out by December 13, 2023. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and/or facility director completed at least 12 clock hours of training annually in one of two applicable records reviewed.
Staff #1 was hired on January 1, 2021 and still a current employee. Staff #1 only had 8 clock hours of documented training completed during the 2022 through 2023 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to more closely align training plan review with annual performance reviews, a decision was made to change the annual training plan year to July 1 through June 30 each year. As a result, the Project Director had training outside of the newly revised training year, and did not get the required 12 hours of training for the training year period of July 1, 2022 through June 30, 2023.
The Compliance Officer sent out a memo to all management and staff regarding the change of the annual training plan year and two set dates each year that are dedicated staff meeting dates to address all training related matters.Those meetings will take place in January and then April. The Clinical Supervisor will be leading those meetings each year. The final review of training will be done in June each year, with the employee and Project Director or Clinical Supervisor.
In addition, the Project Director will create a document for each position that has training hour requirements, timelines for training, and possible training topics. This will be created sent out to all current employees by January 1, 2024. As well, this document will be shared with all newly hired employees, starting January 1, 2024. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a review of the facilities physical plant, the facility failed to ensure that cold foods were kept at or below 40 degrees Fahrenheit.
The refrigerator located upstairs the facility thermometer read 45 degrees Fahrenheit and the refrigerator located downstairs the facility thermometer read 50 degrees Fahrenheit
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the course of attempting to identify what the problems with the refrigerators are, we identified that the upstairs refrigerator's thermostat was not working properly, as well as an issue with the freezer not defrosting properly. We were advised to get a new refrigerator, so we are working on getting one and will have it at the facility by December 10, 2023. In an attempt to address this issue and ensure that refrigerator and freezer temps maintain the appropriate temperatures consistently, and to address any issues that come up immediately. In order to accomplish this, a log sheet was created that has: refrigerator location and temperature, freezer location and temperature, day of check, time of check, and staff initials. The overnight staff on each shift, 7 days a week, will be checking the temps and documenting them on the log sheet. Any temperatures noted lower than the safe standard temperatures will be brought to the Project Director's attention immediately by group message in our workstation space. The Project Director approved this change on 12/4/2023. The form will begin to be used on 12/8/2023. |
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 client records, the facility failed to provide documentation of medications being provided as prescribed by a physician in three of seven records reviewed.
There were blank sections on the MARs in all of the following client records. There was no additional documentation included indicating a reason why the medication was not given as prescribed on those dates.
Client #1 was admitted on June 29, 2023 and discharged on November 6, 2023. The following dates were missing on the MAR: October 15, 2023, and November 2- 6, 2023.
Client #4 was admitted on September 12, 2023 and discharged on October 17, 2023. The following dates were missing on the MAR: October 3, 2023, October 4, 2023, and October 10, 2023.
Client #6 was admitted on July 28, 2023 and still a current client. The following dates were missing on the MAR: September 22-23, 2023, September 27, 2023, October 3, 2023, October 14-15, 2023, October 25, 2023, November 8, 2023 and November 9, 2023 (morning).
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual licensure renewal inspection conducted on January 4, 2023.
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Plan of Correction
The findings related to medication observation related to Client #1, Client #4, and Client #6 were looked at further, following the licensing inspection visit by the Compliance Officer and newly hired Care Coordinator/LPN. There are recurring errors in documentation of medication in the MAR. We have begun putting processes in place to address this issue of medication documentation errors, starting November 15 and continuing (and ongoing). The in-depth review of the client records (1, 2, and 6) showed that medications were not given on those dates but not documented correctly in the MAR. The Care Coordinator and the Compliance Officer developed a plan to ensure medication errors happen at least 80% less than they are currently. The Care Coordinator set up a report to run in our EHR to monitor medication observation records. This report will be run bi-weekly by the Care Coordinator. The Care Coordinator will immediately address issues with the staff observation medications where errors exist. Any medication errors that occur during this internal audit will be fixed within 24 hours of the findings by either the staff observing the errors or the Care Coordinator. The first report will run by the Care Coordinator on 12/8/2023 and will be run every other Friday for at least 4 months. At that time, the Care Coordinator will meet with the Project Director and Compliance Officer to give suggestions as to what interventions need to be put in place to address any ongoing issues/errors/concerns that were found during the internal audit.
As well, the Care Coordinator held an all-staff training on 12/4/2023 related to proper medication observation procedures. The Compliance Officer will write up a memo related to the change, with details about the entire process from entering medications to disposing of old/outdated medications, by 12/14/2023. Because this is a quality issue and has been a consistent shortcoming, the corrective action process, at this point, has no defined end date. At the aforementioned 4 month post-internal audit intervals, the findings will determine the length of corrective action steps. |