INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 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 Mountain Recovery Center 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 document that each counselor met both the education and experience qualifications for the position.
Employee #6, who was hired as a counselor on March 16, 2022 did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project manager and clinical director met on 5/2/2022 to discuss plan of correction. It was determined that Employee #6 would be assigned as a counselor assistant.
Employee #6 will be provided with proper weekly supervision to meet standards and guidelines for that position |
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 seven personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #7 was hired as a counselor assistant on October 18, 2021. Employee #7 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and close supervision for the following nine months. Employee #7 did not have documented direct observation supervision between October 18, 2021, through January 18, 2022. Employee #7 does not have documented close supervision between January 19, 2022 until time of the inspection.
The finding was reviewed with the facility at the time of the inspection.
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Plan of Correction
The project manager and clinical director met on 5/2/2022 to determine plan of correction. On 5/4/2022 the counselor assistant was provided with weekly supervision and direct supervision of individual and group counseling sessions. The counselor assistant will be provided with weekly supervision and direct supervision of individual and group counseling sessions by Clinical Director moving forward |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of nine client records reviewed.
Client #9 was admitted on March 26, 2021 and was still an active client at the time of the inspection. There was documentation that a funding source was contacted on June 30, 2021, August 13, 2021 and October 13, 2021; however there was no consent to release information form signed by the client prior to disclosure.
The finding was reviewed with the facility at the time of the inspection.
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Plan of Correction
The project manager and clinical director met on 5/2/2022 to determine plan of correction. On Thursday 5/5/2022 a clinical meeting was held to review standards of proper consent and signed release by client for release of information to funding source.
Standards will be reviewed in clinical meetings moving forward as indicated |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of five client records reviewed.
Client #6 was admitted on February 17, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was completed on February 24, 2022 and the treatment plan update was due no later than March 24, 2022; however, a treatment plan update was not completed until April 1, 2022.
Client #7 was admitted on December 24, 2021 and was still active at the time of the inspection. A treatment plan was completed on February 8, 2022 and the next treatment plan update was due no later than March 8, 2022; however a treatment plan update was not completed until March 16, 2022.
These findings were reviewed with the facility at the time of the inspection.
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Plan of Correction
The project manager and clinical director met on 5/2/2022 to determine plan of correction.
Clinical meeting was held on 5/5/2022 to review proper standards of treatment plan updates due every 30 days.
It was determined that chart audit forms will be completed weekly by clinical team to assure treatment plan updates will be done no later than 30 days as indicated
The clinical team will meet weekly for 60 minutes to review standards required for treatment plan updates as indicated. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of two client records reviewed.
Client #8 was admitted on February 25, 2020 and was discharge on April 15, 2022. A treatment plan update was completed on January 20, 2022 and the next treatment plan update was due no later than March 20, 2022; however, there was no update documented in the record at the time of the inspection.
Client #9 was admitted on March 26, 2021 and was active at the time of the inspection. A treatment plan update was completed on January 20, 2022 and the next treatment plan update was due no later than March 20, 2022; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with the facility at the time of the inspection.
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Plan of Correction
The project manager and clinical director met on 5/2/2022 to determine plan of correction.
Clinical meeting was held on 5/5/2022 to review proper standards of treatment plan updates due every 30 days.
It was determined that chart audit forms will be completed weekly by clinical team to assure treatment plan updates will be done no later than 30 days as indicated
The clinical team will meet weekly for 60 minutes to review standards required for treatment plan updates as indicated |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a discharge summary in one out of one applicable record reviewed.
Client #8 was admitted on February 25, 2021 and was discharged on April 15, 2022.
The finding was reviewed with the facility at the time of the inspection.
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Plan of Correction
The project manager and clinical director met on 5/2/2022 to determine plan of correction.
Clinical meeting was held on 5/5/2022 to review proper standards of Discharge Summary documentation
It was determined that chart audit forms will be completed weekly by clinical team to assure Discharge Summary documentation is completed in a timely manner
The clinical team will meet weekly for 60 minutes to review standards required for Discharge Summary/Planning |