INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2021- November 17, 2021 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on the review of the facility ' s policy and procedure manual, the facility failed to develop a written policy to address relapse of recovering clinical personnel.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written policy for relapse of recovering clinical personnel was developed at original time of licensing. The policy was not included in the policy packet given to the licensing supervisor at the time of the inspection. The policy was emailed to the licensing supervisor on 11/18/2021. The policy will be reviewed, updated as necessary, and signed annually by the Project Director. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of one applicable personnel file, the facility failed to ensure the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position. Employee #2 was hired as a clinical supervisor on January 1, 2021 and was still current in that position. The facility did not begin to document monthly meetings until October 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 was named as Clinical Supervisor on January 1, 2021. The facility did not start accepting clients until September 9, 2021. The Project Director began monthly supervision with the Clinical Supervisor in October of 2021. As the Project Director failed to provide supervision during the months of January through September 2021, the six (6) month supervision began on October and will be completed in March of 2022. The Project Director will provide monthly supervision on a day/time determined by the Project Director and Clinical Supervisor. The supervision form will be filed in Employee #2 chart. The Program Manager/Compliance Officer will review Employee #2's chart monthly to monitor supervision documentation is completed in a timely manner. |
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 the review of three personnel files, the facility failed to ensure that one counselor qualified for the position.Employee #3 was hired on September 27, 2021 and was current in that position at the time of the inspection. Employee #3 had a qualifying bachelor ' s degree but did not have one year of clinical experience in a health or human service agency.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following guidance from the licensing inspector, Employee #3 was immediately reclassified from Counselor/Lead Clinical Technician to Counselor Assistant by the Project Director and Clinical Supervisor, following a meeting with Employee #3 on 11/20/2021. Employee #3 will be acting as a counselor assistant, until all required hours of supervision, etc. are met. It is estimated that Employee #3 will be in the counselor assistant role until August of 2022. Regular (weekly) supervision is occurring since the week of 11/22/2021 and will continue until the Project Director and Clinical Supervisor assess and make the recommendation for employee #3 to advance to the position of counselor, following DDAP rules for such change. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility ' s policy and procedure manual, the project director failed to 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 an overall plan for addressing staff training needs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Staff Development and Performance Review Policies and Procedures includes a section on Staff Training Guidelines and Training Plan section. This policy and procedures has been updated to include specific personnel named who will be responsible for the direct training plan with all employees and responsible for documentation of training plans with each employee. The Program Manager/Compliance Officer will be the direct person named to work with employees on their training plans. This change became effective 12/15/2021. The Project Director will oversee and monitor the training plans on at least a bi-monthly basis and work with the Program Manager/Compliance Officer on any issues that arise as a result of review of training plans.
Moreover, the training plan year has been set from July 1 to June 30. |
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 the facility ' s policy and procedure manual, the project director failed to 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 a mechanism to collect feedback on completed training.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Staff Development and Performance Review Policies and Procedures (Training Evaluation Section - page 5) has been updated to include who is responsible and the time frames for completion of a mechanism to collect feedback on completed training. Moreover, the training evaluation form created by the Project Director will be reviewed with staff at our January staff meeting. The Project Director approved the revisions to the Training Evaluation section of the policy and procedures on 12/27/2021. As well, the Project Director approved the plan to inform/train our staff on the use of the evaluation form at our next January all staff meeting. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility ' s policy and procedure manual, the project director failed to 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 an annual evaluation of the overall training plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Staff Development, Training, and Performance Review Policies and Procedures has been updated to include who is responsible and the time frames for completion of an annual evaluation of the overall training plan. The policy was written by the Programs Manager and Project Director. The Project Director approved the policy changes on 12/29/2021 and signed/dated the policy change accordingly. |
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 three personnel records and the facility ' s Staffing Requirement Facility Summary Report (SRFSR), the facility failed to develop a written individual training plan for each employee, appropriate to that employee's skill level, within thirty days of hire with input from both the employee and the supervisor, in all records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of licensing inspection, individual staff training plans were developed by the Project Director but not reviewed with staff. Since the inspection, all staff hired between the months of January 2021 and October 2021 have written individual training plans and met with either the Project Director or Programs Manager to review.
There are three staff hired since November to date that have not had a training plan developed as of yet. The Programs Manager will be meeting with the three Clinical Technicians over the next few week, and prior to January 21, 2022, to develop and review the individual training plan, appropriate to their positions at the facility.
The Project Director and Clinical Supervisor approved this plan. The Programs Manager will report to the Project Director and Clinical Supervisor, prior to January 21 to ensure compliance with the development of the training plans with the three newer hired employees.
Going forward, all new employees will work with the Programs Manager during their first 3 weeks of employment to develop the training plan, with input from the employee and the Clinical Supervisor and/or Project Director. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on November 18, 2021, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. The facility ' s dumpster was full, and the cover was open and there were additional items laying on the ground beside the dumpster.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The dumpster that was used from September 9 (day of first residents to arrive at the facility) was a smaller size dumpster. During the weeks prior to our licensing inspection, the number of residents at our facility increased from 8 to 14. This increase caused an overflow of trash in the smaller dumpster. On November 20, the Project Director contacted our hauling service and ordered a new larger (twice the size) dumpster. At this point, the dumpster is being picked up once per week. To date, there have been no issues of overflow of trash while using the larger size dumpster. The Project Director will monitor closely and increase pickup days from one per week to two per week, if necessary. As of now, this issue has been fully addressed and rectified. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide written procedures for staff and residents to follow in case of an emergency that included provisions for the evacuation and transfer of residents impaired by alcohol or other drugs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Emergency and Safety Policy and Procedures includes an evacuation plan in the event of an emergency. However, the plan was missing the provisions for the evacuation and transfer of residents impaired by alcohol or other drugs. This policy was updated to include procedural details regarding how the impaired individuals will be transported off-site, assessed for inpatient detox stay at one of two named facilities in the region, and plans to transport the impaired individual to the detoxification program. The policy/procedure changes were approved by the Project Director on 12/29/2021. |
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 three personnel files and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment. A total of eight staff had not been instructed within seven days of hire in the use of the fire extinguishers.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff hired between the timeframe of September 9 and October 31, were offered fire extinguisher training by a licensed training facility on November 1, 2021. All eight staff referenced herein received the training on November 1. The training was video recorded for use with other newly hired staff.
Going forward, all newly hired staff will complete the fire extinguisher and general emergency training during their first week of employment. A newly created training plan table was created to list all trainings that are required during the first year of employment. The Special Programs Manager will work with all staff to ensure that they watch the fire extinguisher training and practice with the training fire extinguishers purchased by the facility.
The Project Director will meet monthly with the Programs Manager to review required safety trainings. The Project Director approved the use of the aforementioned table and overall plan going forward to ensure compliance with fire extinguisher training. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility ' s fire drill logs from March 2021 to October 2021, the facility failed to conduct unannounced fire drills at least once a month. The facility did not conduct unannounced fire drills from March 2021 to September 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Phoenix Domus, LLC has created the following Plan of Correction in response to not conducting unannounced fire drill during the months of March to September, 2021. As a matte of background, the facility was not occupied during the months of March through September 9, as our first resident came on September 9th, as we officially opened our doors for admission.
The Project Director will ensure that fire drills will occur and be documented in the fire drill log on a monthly basis, including overnight drills to occur every 6 months. To date, there have been a total of four fire drills conducted during the time-frame from September 9 to December 30, 2021.
To ensure that this does not recur, the Project Director will review fire drill log binder monthly to ensure fire drill log has a fire drill conducted. Therefore, meeting DDAP requirements as stated in the DDAP Licensure regulations.
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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 three personnel files and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. No personnel had been trained to perform assigned tasks during emergencies at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Phoenix Domus did train our staff on how to perform assigned tasks during emergencies, during the new staff orientation held over two days on August 30 and August 31. We did fail to document in the employee files that they completed the training related to this deficiency. The Project Director printed out and signed the orientation schedule, to show the training occurred during those two days.
Going forward, all newly hired personnel will be given the training during the new employee orientation sessions that will occur prior to them starting their regular shift work at the facility. The project director will oversee the Programs Manager/Compliance Officer in this area.
Staff hired between the time-frame of September 10 - December 30 (one counselor assistant and three clinical technicians) will be given the in-house one hour training by the Programs Manager over the next 3 weeks, prior to January 21, 2021. |
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 ' s written fire drill logs from March 2021 to October 2021, the facility failed to maintain a written fire drill record including the exit route used, problems encountered and whether the fire alarm or smoke detector was operative.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has revised fire drill log with missing information and will ensure that monthly fire drills are held utilizing all pertinent information per PA Code 705.28 during the drill process. To date Fire Drill Log has been updated with documented problems encountered during the process, specifically, adding the exit routes used; problems encountered during the fire drill, and whether fire alarm was operative. This update was completed and approved by the Project Director on 12/1/2021. |
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 the facility's fire drill logs from March 2021 to October 2021, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was no documentation of a fire drill during sleeping hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Phoenix Domus, LLC has created the following Plan of Correction in response to not conducting overnight fire drill during the months of March to September, 2021. As a matter of background, the facility was not occupied during the months of March through September 9, as our first resident came on September 9th, as we officially opened our doors for admission.
As our facility was out of compliance by not conducting an overnight fire drill during sleeping hours the first six months of our licensing, we conducted an overnight fire drill on December 2 at 12:56 am. Going forward, the overnight fire drills will be conducted every six months, unless otherwise needed/dictated by oversight bodies.
The Project Director will monitor the fire drill log monthly to ensure that the overnight fire drills are happening no more than six months apart. In addition, Fire drill logs are reviewed and discussed among the Project Director, Clinical Supervisor, and Programs Manager monthly, to ensure compliance with the standard as well as to address any issues or concerns that arise. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility ' s written fire drill logs from March to October, the facility failed to prepare alternative exit routes to be used during fire drill. The three fire drills that were conducted utilized the same exit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director developed a plan to alternate exits used during fire drills. There are five exits from the building (3 on the upper level and 2 on the lower level). During each fire drill, one exit on each level will be off-limits for residents to exit. The closed exits will be alternated each month. All staff will be notified of the change via memo and follow-up discussion during the January all-staff meeting.
The plan to alternate exits will begin on the next fire drill.
The Programs Manager will be responsible for closing off exit routes immediately prior to the fire drill and setting off the alarm. When the Programs Manager is not available for fire drills, the Project Director or Clinical Supervisor will be responsible for closing off the exits and setting off the fire alarm. The Project Director will monitor the fire drill log monthly to ensure that alternate exits are being used each monthly fire drill. |
709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on a review of the facility ' s written plan for the coordination of client treatment and rehabilitation services, the facility failed to include written procedures for referral outlining cooperation with other service providers including provisions for access to emergency services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Treatment and Rehabilitation Management Policy and Procedures has been updated to include a section on "Coordination of Care and Referral Services" (including a section on provisions for access to emergency services). This policy was updated by the Programs Manager and Project Director and was approved by the Project Director on 1/3/2022. Staff will be notified of the changes during the February all-staff meeting. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the facility ' s policy and procedure manual, the governing body failed to adopt and implement written project personnel policies and procedures to include the utilization of volunteers. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written policy for how volunteers will be utilized was developed at original time of licensing. The policy was not included in the policy packet given to the licensing supervisor at the time of the inspection. The policy was emailed to the licensing supervisor on 11/18/2021. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of the facility ' s policy and procedure manual, the governing body failed to adopt and implement written project personnel policies and procedures to include rules of conduct.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Phoenix Domus Employee Handbook contained some policies and procedures, to include rules of conduct. The Programs Manager pulled information from the employee handbook, added more details to the rules of conduct section, and revised other components, in order to align more closely to the standard. The result is a stand-alone policy and procedure related to rules of conduct for employees. The Project Director reviewed the policy and procedure on 12/29/2021 and suggested changes. The Programs Manager made the recommended changes and resubmitted to the Project Director on 12/20/2021. The Project Director approved and signed the new policy and procedure document on 12/30/2021. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on a review of the facility ' s policy and procedure manual, the governing body failed to adopt and implement written project personnel policies and procedures to include supervision of staff.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written policy for Supervision of Staff was developed at original time of licensing. The policy was not included in the policy packet given to the licensing supervisor at the time of the inspection. The policy was emailed to the licensing supervisor on 11/18/2021. The policy will be reviewed, updated as necessary, and signed annually by the Project Director. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on a review of the facility ' s policy and procedure manual, the project director failed to develop a written procedure which includes 4 Pa. Code 255.5. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our original policy and procedure for Confidentiality and Release of Resident Records was written based on the Federal Regulation 42 CFR and did not include policy and procedure for 4 Pa. Code 255.5. The policy was completely revised on 12/21/2021 and sent to the Project Director for review. The Project Director reviewed the document and made recommendations for change, based on the PA Code. The policy/procedure was revised again and sent back to the Project Director for review and approval. The Project Director approved the revised policy on 12/28/2021. The policy addresses all pertinent information related to 4 Pa. Code 255.5, including the implementation of the 5-Point Release of Information. Changes will be reviewed with all staff during our January all-staff meeting. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the facility ' s policy and procedure manual, the project director failed to develop a written procedure which includes confidentiality of client identity and records including a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our original policy and procedure for Confidentiality and Release of Resident Records was written based on the Federal Regulation 42 CFR and did not include a written procedure which includes confidentiality of client identity and records, including a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records. The policy was completely revised on 12/21/2021 and sent to the Project Director for review. The Project Director reviewed the document and made recommendations for change, based on the PA Code.
Phoenix Domus uses Electronic Health Records (EHR) for all resident-related documentation. Only staff completing the required Confidentiality training will be given access to the confidential resident records. Staff, following the required confidentiality training, permitted to access resident records include: Phoenix Domus halfway house Director, Clinical Supervisor, Special Programs Manager, Counselors/Counselor Assistant, and Clinical Technicians. The Programs Manager/Compliance Officer, in cooperation with the Project Director and Clinical Supervisor is responsible for the overall maintenance of resident records in the EHR. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in six client records reviewed.Client #2 was admitted on October 17, 2021 and discharged on November 9, 2021. An informed and voluntary consent for a medical facility signed and dated by the client on October 18, 2021 listed the specific information to be disclosed as " other. "Client #3 was admitted on November 4, 2021 and discharged on November 10, 2021. Three informed and voluntary consents signed and dated by the client on November 4, 2021, for a previous facility, a former counselor, and a medical provider listed the specific information to be disclosed as " other. "Client #4 was admitted on October 5, 2021 and was current at the time of the inspection. An informed and voluntary consent for a family member signed and dated October 6, 2021 listed the specific information to be disclosed as " other. "Client #5 was admitted on November 10, 2021 and was current at the time of the inspection. An informed and voluntary consent for a family member signed and dated November 10, 2021 listed the specific information to be disclosed as " other. "Client #6 was admitted on September 17, 2021 and was current at the time of the inspection. Informed and voluntary consents for a pharmacy and girlfriend signed and dated on September 17, 2021 listed the specific information to be disclosed as " other. " An informed and voluntary consent for a government agency signed and dated on September 17, 2021 listed the specific information to be disclosed as " other and 5 points. "Client #7 was admitted on October 13, 2021 and was current at the time of the inspection. Informed and voluntary consents for medical provider and a government agency signed and dated on October 15, 2021 listed the specific information to be disclosed as " other. " An informed and voluntary consent for a government agency signed and dated on October 21, 2021 listed the specific information to be disclosed as " 5 points. " These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In light of our shortcomings in this area, and with guidance from the DDAP licensing inspector, we made several changes to the process of processing our Release of Information forms in our EHR. To note, the Project Director, Clinical Supervisor, and Programs Manager met to make a plan to correct the errors in this area of confidentiality and release of information. The result was implementation of a new process to complete release of information forms (begin during intake with only the necessary release of information forms and add any additional necessary as the need arises. A separate consent to persons listed under 4 PA Code 255.5 has been created in the system to limit the amount of information disclosed.
Client #2 was admitted on October 17, 2021 and discharged on November 9, 2021. An informed and voluntary consent for a medical facility signed and dated by the client on October 18, 2021 listed the specific information to be disclosed as " other. " No further action was taken on client #2, as he was discharged prior to licensing inspection.
Client #3 was admitted on November 4, 2021 and discharged on November 10, 2021. Three informed and voluntary consents signed and dated by the client on November 4, 2021, for a previous facility, a former counselor, and a medical provider listed the specific information to be disclosed as " other. " No further action was taken on client #3, as he was discharged prior to licensing inspection..
Client #4 was admitted on October 5, 2021 and was current at the time of the inspection. An informed and voluntary consent for a family member signed and dated October 6, 2021 listed the specific information to be disclosed as " other. " This form has been revoked and replaced with the new form.
Client #5 was admitted on November 10, 2021 and was current at the time of the inspection. An informed and voluntary consent for a family member signed and dated November 10, 2021 listed the specific information to be disclosed as " other. " This form has been revoked and replaced with the new form.
Client #6 was admitted on September 17, 2021 and was current at the time of the inspection. Informed and voluntary consents for a pharmacy and girlfriend signed and dated on September 17, 2021 listed the specific information to be disclosed as " other. " An informed and voluntary consent for a government agency signed and dated on September 17, 2021 listed the specific information to be disclosed as " other and 5 points. " These forms have been revoked and replaced with the new form.
Client #7 was admitted on October 13, 2021 and was current at the time of the inspection. Informed and voluntary consents for medical provider and a government agency signed and dated on October 15, 2021 listed the specific information to be disclosed as " other. " An informed and voluntary consent for a government agency signed and dated on October 21, 2021 listed the specific information to be disclosed as " 5 points. " These forms have been revoked and replaced with the new form. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of one applicable record, the facility failed to notify the client in writing of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.Client #2 was admitted on October 17, 2021 and discharged on November 9, 2021. There was no documentation in the client record that the facility notified the client in writing of a decision to involuntarily terminate the client ' s treatment at the project.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Previously, an involuntary discharge was preceded by either a breach in a behavior contract or refusal to sign a behavior contract, upon request by either the Project Director, Clinical Supervisor, Programs Manager (or a combination thereof). Documentation was done by completing discharge documentation in the EHR. We failed provide Client #2 in writing of a decision to involuntarily terminate the resident's treatment at the project.
We are currently working with our EHR provider company to develop an "Involuntary Termination of Treatment Form". The software company estimates its completion by January 12, at which time it'll be added to our EHR system and then utilized for involuntary discharges. In the interim, a temporary form has been created and approved by the Project Director to use, in case any involuntary discharges occur between today and roll-out of the form in our EHR (estimated date for full roll-out is January 21, 2022. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of one applicable record, the facility failed to inform the client that they have an opportunity to request reconsideration of a decision terminating treatment.Client #2 was admitted on October 17, 2021 and discharged on November 9, 2021. There was no documentation in the client record that the facility notified the client that they have an opportunity to request reconsideration of a decision terminating treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 was discharged on November 9, 2021 and was not notified that he has an opportunity to request reconsideration of a decision to terminate his treatment. An attempt was made on 12/27/2021 to contact the former resident to let him know of his right to request a reconsideration to terminate his treatment. PD staff were not able to reach Client #2.
Going forward, a new form has been created for the resident being involuntarily discharged to request reconsideration of termination of treatment. This form was completed and approved by the Project Director on 1/3/2022 and reviewed with all members of the management and counseling teams. This form will be used for all involuntary discharges and will be uploaded into the resident's record in the EHR. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of seven client records, the facility failed to have intake procedures that included documentation of the client orientation to the project which includes a familiarization with the fee schedule in all records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A fee schedule is being developed now by the Project Director and Programs Manager. A meeting with our accountant is being scheduled to review the fee schedule. Input from the local SCA and our HealthChoices network providers will be sought, prior to fully implementing the fee schedule. Once the fee schedule is approved and fully implemented (by 2/1/2022), residents will sign off stating that the fee schedule was discussed with them during the intake process. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of seven client records, the facility failed to have intake procedures that included documentation of a physical examination in two out of four applicable records reviewed.Client #4 was admitted on October 5, 2021 and was current at the time of the inspection. There was no documentation of a physical examination in the client record. Client #7 was admitted on October 13, 2021 and was current at the time of the inspection. There was no documentation of a physical examination in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Currently, our facility accepts physical exams completed at a referring facility as a component of the intake process, as long as physical exams are completed within the previous 12 months, prior to date of admission into our program.
Client #4 was admitted as a self-referral on 10/5/2021. As such, no physical exam was completed and sent to us from a referring facility. Client #4 was scheduled and attended an appointment with a primary care physician that was set up by the client and his counselor. Client #4 attended his physical examination appointment. We are currently waiting for his paperwork to be given to us.
Client #7 was admitted as a self-referral on 10/5/2021. As such, no physical exam was completed and sent to us from a referring facility. Client #4 was scheduled and attended an appointment with a primary care physician that was set up by the client and his counselor. Client #4 attended his physical examination appointment. We are currently waiting for his paperwork to be given to us.
As a result of physicians being backlogged with appointment requests at the times of admission of both Client #4 and Client #7, it took over a month to get them an appointment with their PCP. The Project Director, Clinical Supervisor, and Programs Manager met to address this concern. We did find a physician group, Caring Health Network that has been accepting our residents and getting them in to appointments with teh doctor right away.
To ensure that our residents get physicals in a timely manner upon arrival, we will primarily utilize the physician group referenced above.
As a backup, we will contract with either a Physician Assistant or Nurse Practitioner (CRNP) on an as-needed basis (PRN) before March 1, 2022. The process of searching for either a PA or CRNP has begun. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two of four applicable records reviewed. Client #4 was admitted on October 5, 2021 and was current at the time of the inspection. Client #4 ' s treatment and rehabilitation plan dated November 5, 2021 listed individual sessions four times a week. Only one individual session was documented each week. Client #6 was admitted on September 17, 2021 and was current at the time of the inspection. Client #6 ' s treatment and rehabilitation plan dated October 8, 2021 listed individual sessions five times a week. Only one individual session was documented each week. The only documented individual sessions in client record following the treatment and rehabilitation plan were on October 11, 2021 and October 30, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility is new and is using a new Electronic Health Record (EHR) system. As such, staff are still learning the system. There were errors by two counselors when developing treatment plans, to include showing more individual counseling sessions than are being offered.
Client #4's treatment and rehabilitation plan dated November 5, 2021 listed individual sessions four times a week in error. The residents get one mandatory counseling session per week (and others as needed/counselor or counselor assistant is available). The treatment plan has been fixed/updated to show one (1) individual counseling session per week.
Client #6's treatment and rehabilitation plan dated October 8, 2021 listed individual sessions five times a week in error. Only one (1) session was held and was documented each week.The residents get one mandatory counseling session per week (and others as needed/counselor or counselor assistant is available). The treatment plan has been fixed/updated to show one (1) individual counseling session per week. Also, with Client #6, the counselor did not sign all of the notes in the EHR. As a result, the notes that were documented here as missing were there, but not signed/finalized and showing as completed in the EHR. This issue was resolved on 11/19/2021.
To avoid this from happening again, the Project Director and Clinical Supervisor are reviewing client records at least twice per week, looking at notes, reviewing treatment plans, etc.. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to develop a complete client record on an individual which includes information relative to the client's involvement with the project including verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility failed to develop a complete client record on an individual which includes information relative to the client's involvement with the project including verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven records reviewed.
We are currently in the process of full implementation of one standard ASAM treatment plan, created for us by our EHR software team, in cooperation with the Project Director, Clinical Supervisor, and Programs Manager. The treatment plan is complete and is currently being implemented for each resident, as their treatment plan update date comes due. We are working with the software company to determine where, in the ASAM criteria, it'll be best to include the resident facility work goal. We estimate this process to be completed fully by February 10, 2022. The Project Director and Clinical Supervisor will monitor progress. The Programs Manager will act as the key contact with the EHR software company. |