INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Serenity Behavioral Health 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility ' s January 2021 through December 2021 training year in two of two applicable personnel records reviewed.
Employee #2 was hired as a counselor on August 13, 2020. The personnel record documented 6.5 hours of annual training for the reviewed training year.
Employee #3 was hired as a counselor on December 3, 2020. The personnel record documented 16.5 hours of annual training for the reviewed training year.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program director reviewed training requirements with all staff members on 3/18/2022. Program director and office manager will follow the plan outlined in the "Overall plan to address needs identified in staff assessment of trainings" that was completed on 1/20/2022 which includes: Emailing staff members upcoming training and CEU events, creating a schedule for in house trainings that will be conducted bi-monthly after staff meeting and will equal 8-12 training hours per year. Office Manager or program director will also conduct bi annual reviews of staff training hours to ensure required completion of hours. Staff who are not on track to complete the required hours will meet with the program director to create a training schedule for the remainder of the year. |
709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in five of seven client records reviewed.
The policy and procedure manual stated that the biopsychosocial evaluation will be completed at initial assessment/within 7 days of admission and was not followed in two client records.
Client #1 was admitted on May 18, 2021 and was active at the time of inspection. The biopsychosocial evaluation was due no later than May 25, 2021; however, the evaluation was signed and completed by the counselor on June 28, 2021.
Client #5 was admitted on June 18, 2021 and was discharged on December 8, 2021. The biopsychosocial evaluation was due no later than June 25, 2021; however, the evaluation was signed and completed by the counselor on June 29, 2021.
Additionally, the policy and procedure manual stated that progress notes will be completed within 7 days and was not followed in one client record.
Client #2 was admitted on May 26, 2021 and was active at the time of inspection. A counseling session occurred on August 3, 2021; however, the progress note was signed and completed by the counselor on October 26, 2021. Additionally, a counseling session occurred on September 24, 2021; however, the progress note was signed and completed by the counselor on December 2, 2021. Also, a counseling session occurred on October 13, 2021; however, the progress note was signed and completed by the counselor on December 2, 2021. Finally, a counseling session occurred on December 1, 2021; however, the progress note was signed and completed by the counselor on January 17, 2022.
Finally, the policy and procedure manual stated that aftercare plans will be completed prior to discharge and was not followed in two client records.
Client #6 was admitted on May 10, 2021 and was discharged on September 6, 2021. The aftercare plan was due prior to discharge; however, the plan was signed and completed by the counselor on December 13, 2021.
Client #7 was admitted on July 6, 2021 and was discharged on October 29, 2021. The aftercare plan was due prior to discharge; however, the plan was signed and completed by the counselor on February 23, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/18/2022 program director updated the facilities policy and procedures to reflect accurate paperwork due date requirements. All staff were informed of the following changes on 3/18/2022:
Biopsychosocials: will be completed within 30 days of admission
Aftercare plans: In order to clarify that the completed aftercare plan is due upon discharge, language in the policy and procedures was updated from: "It is the responsibility of the primary therapist to work with the client to develop an aftercare plan prior to discharge from the program" to "It is the responsibility of the primary therapist to work with the client to develop an aftercare plan which is to be completed no later than the date of discharge from the program"
Progress notes: An additional outdated document was incorrectly placed in the policy and procedure binder that was provided to DDAP. This document was removed. The policy and procedures does not have a specified due date for progress notes.
Program director will also complete quarterly chart reviews to ensure accurate and timely completion of documentation.
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #6 was admitted on May 10, 2021 and was discharged on September 6, 2021. There was a family session that occurred on July 16, 2021; however, there was no consent to release information form to the family member signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 3/18/2022 program director reviewed written documentation guidelines for informed and voluntary consent form for the disclosure of information contained in the client record. Staff were reminded that Family sessions may only be conducted with individuals that the client has signed a consent to release information form for. Staff members will ensure a signed consent to release information form is signed and documented in the client's chart for each individual participating prior to the start of the session. |
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 client records, the facility failed to keep disclosures of client identifying information within the limits established for releases of information in five of seven client records reviewed.
Client #1 was admitted on May 18, 2021 and was active at time of inspection. Two release of information forms to separate family members were signed and dated by the client on May 18, 2021 that only allowed for the release of whether the client is or is not in treatment, the prognosis of the client, the nature of the project, the progress of the client and the relapse history. There were family contact notes throughout treatment and a family session on October 18, 2021, which released information that was in excess to the specific information documented on the release forms.
Client #2 was admitted on May 26, 2021 and was active at time of inspection. Two release of information forms to separate family members were signed and dated by the client on May 25, 2021 that only allowed for the release of whether the client is or is not in treatment, the prognosis of the client, the nature of the project, the progress of the client and the relapse history. There were family contact notes throughout treatment and family sessions on July 21, 2021, August 11, 2021, and December 6, 2021, which released information that was in excess to the specific information documented on
the release forms.
Client #3 was admitted on July 28, 2021 and was active at the time of inspection. Two release of information forms to separate family members were signed and dated by the client on July 26, 2021 that only allowed for the release of whether the client is or is not in treatment, the prognosis of the client, the nature of the project, the progress of the client and the relapse history. There were family contact notes throughout treatment and family sessions on October 25, 2021 and January 13, 2022, which released information that was in excess to the specific information documented on the release forms.
Client #4 was admitted on May 17, 2021 and was discharged on December 16, 2021. Two release of information forms to separate family members were signed and dated by the client on May 17, 2021 that only allowed for the release of whether the client is or is not in treatment, the prognosis of the client, the nature of the project, the progress of the client and the relapse history. There were family contact notes throughout treatment and a family session on October 20, 2021, which released information that was in excess to the specific information documented on the release forms.
Client #6 was admitted on May 10, 2021 and was discharged on September 6, 2021. A release of information form to a family member was signed and dated by the client on May 10, 2021 that only allowed for the release of whether the client is or is not in treatment, the prognosis of the client, the nature of the project, the progress of the client and the relapse history. There were family contact notes throughout treatment and a family session on July 16, 2021, which released information that was in excess to the specific information documented on the release forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/18/2022 staff were informed that the client or family members voluntary disclosure of additional information to individuals during a family session fails to remain within the following limits established for releases of information: "The release of whether the client is or is not in treatment, the prognosis of the client, the nature of the project, the progress of the client and the relapse history."
Staff were informed that in order for the client and/or family members (and/or therapist) to discuss additional topics in sessions involving family members "other" must be checked on the ROI and "information pertaining to family therapy" must be written on the line titled "Details for other".
Staff were reminded to check to the presence of a signed release and the information authorized for disclosure prior to conducting family sessions.
Program director will also complete quarterly chart reviews to ensure appropriate and timely completion of consents to release information. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to appropriately document a dated signature of the witness on release of information forms in one of seven client records reviewed.
Client #7 was admitted on July 6, 2021 and was discharged on October 29, 2021. A release of information form to the funding source was signed and dated by the client on July 3, 2021; however, the dated signature of the witness was documented on July 5, 2021.
This is a repeat citation from the April 21, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director reviewed release of information policies with all staff members on 3/18/22. Staff were reminded to ensure appropriate documentation of a dated client and witness signature. Program director also confirmed the system was configured to require a witness signature in order to be submitted by the client when collected electronically. Program director will complete quarterly chart reviews to ensure documentation is appropriately completed. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to assure that counseling services were being provided to the client, according to the individual treatment and rehabilitation plan, in six of seven client records reviewed.
Client #1 was admitted on May 18, 2021 and was active at the time of inspection. The comprehensive treatment plan dated May 25, 2021 and treatment plan updates dated July 27, 2021, September 24, 2021, November 22, 2021, and January 19, 2022, specified group sessions 2-4x per week and weekly individual sessions. There was no documentation in the record of group or individual counseling sessions during the weeks of September 12, 2021 - September 25, 2021 and during the weeks of November 28, 2021 - January 1, 2022. Additionally, there were no individual counseling sessions during the weeks of October 3, 2021 - October 9, 2021, October 17, 2021 - November 6, 2021.
Client #2 was admitted on May 26, 2021 and was active at the time of inspection. Treatment plan updates dated July 20, 2021, September 18, 2021, November 17, 2021, and January 16, 2022 specified group sessions 2-4x per week and weekly individual sessions. There was no documentation in the record of individual counseling sessions during the weeks of September 5, 2021 - September 11, 2021, September 26, 2021 - October 16, 2021, October 24, 2021 - November 13, 2021, December 12, 2021 - December 25, 2021, and January 16, 2022 - January 22, 2022.
Client #3 was admitted on July 28, 2021 and was active at the time of inspection. The comprehensive treatment plan dated August 3, 2021 and treatment plan updates dated October 1, 2021, November 30, 2021, and January 22, 2022 specified group sessions 2-4x per week and weekly individual sessions. There was no documentation in the record of individual counseling sessions during the weeks of August 29, 2021 - September 4, 2021, November 7, 2021 - November 13, 2021, December 5, 2021 - December 25, 2021, and January 2, 2022 - January 8, 2022.
Client #4 was admitted on May 17, 2021 and was discharged on December 16, 2021. Treatment plan updates dated July 15, 2021, September 14, 2021, and November 13, 2021 specified group sessions 2-4x per week and weekly individual sessions. There was no documentation in the record of individual counseling sessions during the weeks of September 5, 2021 - September 18, 2021, October 17, 2021 - October 23, 2021, October 31, 2021 - November 6, 2021, and November 21, 2021 - November 27, 2021.
Client #6 was admitted on May 10, 2021 and was discharged on September 6, 2021. A treatment plan update, dated July 9, 2021, specified weekly individual counseling sessions. There was no documentation in the record of individual counseling sessions during the weeks of July 25, 2021 - August 28, 2021.
Client #7 was admitted on July 6, 2021 and was discharged on October 29, 2021. The comprehensive treatment plan dated July 8, 2021 and a treatment plan update, dated September 6, 2021, specified weekly individual counseling sessions. There was no documentation in the record of individual counseling sessions during the weeks of July 18. 2021 - July 24, 2021, August 15, 2021 - September 11, 2021, September 19, 2021 - September 25, 2021, and October 3, 2021 - October 23, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/18/2022 program director informed all staff that missed appointments and/or cancelations must be documented in the client's chart. Staff will document, in writing the missed and/or cancelled appointment and reason(when known). |