INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2024, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of five personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in one of two applicable records.
Employee # 4 was hired by the facility as a counselor assistant on September 27, 2023. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision in each week reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/6/24 program director reviewed the citation with staff and updated the supervision note form to include a check box for "direct observation of clinical services" Clinical supervisor will be responsible for ensuring that weekly supervision notes document that direct observation of counseling services was part of the supervision provided. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on February 2, 2024, the facility failed to ensure that exits from the nonresidential facility were unobstructed, as the emergency exit on the Eagle Street side of the building was obstructed by the low awning above it, which prevented the door from opening fully.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/3/2024 the emergency exit door was fixed and the exit is no longer obstructed. All emergency exits will be regularly checked by the program director and/or office manager during fire drills to ensure they remain unobstructed. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in four of seven applicable client records reviewed.
Client # 1 was admitted on April 12, 2023 and was discharged on November 28, 2023. The individual treatment and rehabilitation plan was completed on April 14, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 4 was admitted on October 24, 2023 and was discharged on January 5, 2024. The individual treatment and rehabilitation plan was completed on October 27, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 6 was admitted on November 22, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 4, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 7 was admitted on October 17, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 25, 2023; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/6/24 the program director updated the the client needs section of the treatment plan to include the option to select "client declined additional support services". The citation was reviewed with clinical staff and they were instructed to select the recommended support services or document the denial of additional services. The EHR system was also updated to require a selection in order for the treatment plan to be marked as completed. |