INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2025, 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 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 eight personnel records, the facility failed to ensure that one counselor assistant with a high school diploma or GED equivalent counseled clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment.
Employee #8 was hired on February 19, 2025, as a counselor assistant and is still current in that position. Employee #7 has a high school diploma and may only counsel clients under the direct supervision of a trained counselor or clinical supervisor for the first three months of employment. Employee #7 had supervision notes from February 27, 2025-March 14, 2025, that did not identify direct observation was occurring.
"Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " .
In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or
counselor is then responsible for weekly supervision notes relating to the counselor assistant.
Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring. "
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: L0049 ? Supervision of Counselor Assistants
Facility Name: Serenity Mountain Recovery Center
Facility License Number: 647023
Correction Due Date: 4/3/2025
Submitted By: Clinical Director
Regulatory Citation ? 28 Pa. Code § 704.7 (b)
"A counselor assistant shall be under the direct supervision of a clinical supervisor or a counselor. The supervision shall include a review of the client record, client progress, and the counselor assistant's development of counseling skills. Supervision shall be documented and the documentation shall include the date, duration, and content of the supervision."
Deficiency Identified:
During the audit, it was found that documentation of supervision for counselor assistants was either missing, incomplete, or inconsistent with the requirements outlined in L0049. Specific deficiencies included:
Missing supervision logs
Plan of Correction:
1. Policy Implementation:
A formal written Supervision Policy has been developed and approved by leadership to outline expectations, frequency, and documentation procedures.
The policy mandates weekly documented supervision for all counselor assistants.
2. Supervisor Assignment and Training:
Each counselor assistant is assigned a designated clinical supervisor.
All supervisors have completed a refresher training on DDAP standards for counselor assistant supervision, documentation, and responsibilities. Training was completed on [4/3/2025].
3. Documentation Process:
A standardized Supervision Log Template has been created and implemented. The form includes:
Date and duration of supervision
Detailed notes on client progress review
Specific skills discussed and areas of counselor assistant development
Supervision documentation is now reviewed monthly by the Clinical Director to ensure compliance.
4. Record-Keeping:
All supervision logs are stored in the counselor assistant's personnel file and cross-referenced with client records when applicable.
Logs are maintained in hard copies in secure staff files.
5. Audit and Compliance Checks:
Internal audits of supervision records will be conducted quarterly by the Quality Assurance team to ensure adherence and identify any trends or gaps.
Completion Date of Correction:
4/3/2025
Person Responsible for Oversight:
Clinical Director
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on review of eight personnel record the facility failed to ensure that all personnel on all shifts are trained in the use of fire extinguishers upon staff employment.
Employee #8 was hired as a counselor assistant on February 19, 2025, and was still in the position at the time of the inspection. There was no documentation that employee #8 was trained in the use of fire extinguishers upon employment.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction: L0276 ? Fire Extinguisher Training Upon Employment
Facility Name: Serenity Mountain Recovery Center
Facility License Number: 647023
Correction Due Date: 3/28/2025
Submitted By: Clinical Director
Regulatory Citation ? 28 Pa. Code § 705.28 (d)(4)
"All personnel on all shifts shall be trained to perform assigned tasks during emergencies. Training shall be provided in the use of fire extinguishers upon staff employment."
Deficiency Identified:
During the audit, it was found that Employee #8, hired as a counselor assistant on February 19, 2025, did not have documentation of fire extinguisher training completed upon employment, as required. This lapse in compliance was acknowledged and reviewed during the licensing inspection.
Plan of Correction:
1. Immediate Corrective Action:
Employee #8 completed fire extinguisher training on 2/19/2025 although had failed to sign the attestation form. This has been rectified, the form has been signed and is present in her file.
Documentation of this training has been filed in Employee #8's personnel file.
Training included a review of facility evacuation procedures and a live demonstration of extinguisher use.
2. Policy Reinforcement:
The facility's new hire onboarding checklist has been updated to include fire extinguisher training as a mandatory task to be completed within the first 24 hours of employment.
Supervisors are now required to verify and sign off on completed fire extinguisher training before new employees are permitted to begin shift duties.
3. Training Procedure:
Fire extinguisher training is conducted by the Operations or Safety Officer and includes:
A hands-on demonstration
Review of the PASS (Pull, Aim, Squeeze, Sweep) method
Location and accessibility of extinguishers within the facility
Documentation using a standardized Fire Safety Training Form
4. Monitoring and Compliance:
A monthly personnel file audit will be conducted by the HR Department to ensure all new hire documentation is complete and compliant.
The Clinical Director and HR Manager will review onboarding records jointly at the end of each month for quality assurance.
5. Staff Re-Education:
A mandatory fire safety refresher training was provided to all staff on [Insert Date], covering extinguisher use and emergency protocols.
This training will now be conducted annually for all staff, regardless of position or shift.
Completion Date of Correction:
3/28/2025; and will continue to be reviewed with all staff annually starting 1/02/2026.
Person Responsible for Oversight:
Human Resources Manager
Clinical Director. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of seven records reviewed.
Client #6 was admitted on November 19, 2024, and was still active at the time of the inspection. There was documentation that information was disclosed to the client ' s county case manager on December 9, 2024, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information until December 20, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action Plan: Informed and Voluntary Consent for Disclosure of Information
Facility Name: Serenity Mountain Recovery Center
Regulatory Citation ? 28 Pa. Code § 709.28 (c)(1)
"A client's records must contain documentation of informed and voluntary consent from the client for the disclosure of any information to any outside entity or individual, in accordance with 4 Pa. Code § 255.5 and federal confidentiality laws (42 CFR Part 2)."
Deficiency Identified:
During the review of seven client records, it was determined that Client #6, admitted on November 19, 2024, had documentation showing that information was disclosed to the client's county case manager on December 9, 2024, prior to obtaining informed and voluntary written consent. Consent documentation was not signed until December 20, 2024, in violation of applicable state and federal confidentiality regulations.
Plan of Correction:
1. Immediate Corrective Action:
A thorough audit of all active client records was conducted to verify the presence of proper consents for all disclosures.
No further unauthorized disclosures were identified.
The staff member involved in the incident received formal re-education and supervision on client confidentiality and the legal requirements for consent under 42 CFR Part 2 and PA 255.5.
*****The client's chart in question, was corrected on December 20,2024 as noted in the observation #0276.
2. Policy and Procedure Review:
The facility's Confidentiality and Release of Information Policy has been revised to emphasize:
No disclosures of any client information shall occur without a properly signed consent form in the chart.
Verbal consents are not permitted under any circumstances for documented disclosures.
3. Staff Training and Accountability:
All clinical and administrative staff were retrained on:
The legal standards for informed and voluntary consent
Acceptable formats for consent under DDAP and federal confidentiality law
Proper documentation procedures
Training occurred on 4/3/2025 and was documented in the group supervision note.
4. New Quality Assurance Procedure:
The Clinical Director will conduct a weekly chart audit on all new admissions to verify that:
All required consents are signed prior to any disclosures
Disclosures are accurately logged with dates matching consent forms
A Release of Information Checklist has been added to all new intake packets to ensure nothing is missed prior to any communication with outside parties.
5. Ongoing Monitoring:
The QA team will perform monthly audits on 10% of active charts to assess continued compliance.
Any identified deficiencies will be addressed immediately with documented corrective supervision or additional staff education.
Completion Date of Correction:
4/3/2025
Person Responsible for Oversight:
Clinical Director
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in one out of seven records reviewed.
Client #7 was admitted on August 19, 2024, and was discharged on December 29, 2024. An informed and voluntary consent from the client for the disclosure of information to a prior facility, signed and dated August 19, 2024, did not include the purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Name: Serenity Mountain Recovery Center
Regulatory Citation ? 28 Pa. Code § 709.28 (c)(1)
"A client's records must contain documentation of informed and voluntary consent from the client for the disclosure of information. Each consent to release information shall include the specific information to be disclosed, the purpose of the disclosure, the person or entity to whom the disclosure is to be made, and the expiration date of the consent."
Deficiency Identified:
Upon review of client records, it was determined that Client #7, admitted on August 19, 2024 and discharged on December 29, 2024, had a signed consent form for the disclosure of information to a prior treatment facility. However, the form, signed on August 19, 2024, did not include the required "purpose of disclosure", resulting in an incomplete consent that does not meet regulatory standards.
Plan of Correction:
1. Immediate Remediation:
A full review of all current and recently discharged client records was conducted to identify any other consent forms missing required elements.
No other omissions were found.
2. Consent Form Revision:
The facility has revised the standard Release of Information (ROI) form to:
Include a clearly labeled and mandatory field for the "Purpose of Disclosure"
Prevent submission or filing of incomplete forms by making all fields required before acceptance
The updated form was implemented on 4/3/2025.
3. Staff Education:
All clinical staff, case managers, and admissions personnel received mandatory re-training on:
The legal and ethical importance of fully informed consent
Federal (42 CFR Part 2) and state (PA § 709.28) consent requirements
How to properly complete and verify all fields of the revised ROI form
Training was completed on 4/3/2025 and documented in group supervision note/agenda.
4. Quality Assurance Monitoring:
A Consent Compliance Checklist has been added to every new client intake packet and must be signed off by both the admitting clinician and a supervisor.
The Clinical Director will audit all new consents within 48 hours of intake to ensure completeness and regulatory compliance.
Ongoing, the QA team will perform bi-weekly chart audits on a rotating sample of client records.
Completion Date of Correction:
4/3/2025.
Person Responsible for Oversight:
Clinical Director
In this position starting 3/6/2025. |
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 at least every 30 days in three out of seven client records reviewed.
Client #3 was admitted on June 19, 2024, and discharged on December 16, 2024. A treatment plan update was completed on September 26, 2024, and the next update was due no later than October 26, 2024; however, there was no documentation in the client record that it was completed.
Client #6 was admitted on November 19, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 26, 2024, and the treatment plan update was due no later than December 26, 2024; however, it was not completed until January 29, 2025.
Client #7 was admitted on August 19, 2024, and was discharged on December 29, 2024. A comprehensive treatment plan was completed on August 21, 2024, and the treatment plan update was due no later than September 21, 2024; however, it was not completed until October 18, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Name: Serenity Mountain Recovery Center
Regulatory Citation ? 28 Pa. Code § 709.92 (b)
"The individual treatment and rehabilitation plan shall be reviewed and updated at least every 30 days."
Deficiency Identified:
Based on a review of seven client records, three were found to be out of compliance with the 30-day treatment plan update requirement:
Client #3: Admitted on June 19, 2024; last update on September 26, 2024. Next update due October 26, 2024, but not completed.
Client #6: Admitted on November 19, 2024; initial plan on November 26, 2024, update due by December 26, 2024, but completed late on January 29, 2025.
Client #7: Admitted on August 19, 2024; initial plan on August 21, 2024, update due by September 21, 2024, but completed late on October 18, 2024.
Plan of Correction:
1. Immediate Corrective Action:
An audit of all active client records was completed within 48 hours of the citation to ensure compliance with treatment plan update timelines.
Late or missing updates were completed immediately, and clinical staff were individually notified and retrained.
Any upcoming due dates for treatment plan reviews were scheduled and prioritized.
2. Staff Education and Re-training:
All clinical staff were re-educated on:
DDAP's 30-day treatment plan update requirement
Importance of timely documentation for compliance and continuity of care
This training was completed on 4/3/2025 and documented in group supervision notes.
A treatment planning refresher is now be required annually for all clinicians. The next training is scheduled for 5/8/2025.
3. Quality Assurance Implementation:
A Treatment Plan Tracker was created using a spreadsheet-based system to:
Be reviewed weekly by Clinical Director who will then place an alert on the calendar when treatment plan updates are due.
Provide weekly reports to the Clinical Supervisor for monitoring
Weekly QA meetings will include a chart review section to ensure treatment plan timelines are being met.
4. Clinical Supervision & Oversight:
The Clinical Director will sign off on all treatment plans and updates to verify they are completed on time and meet clinical standards.
Supervisors are required to check due dates during weekly supervision and case reviews.
5. Policy Review:
The facility's Clinical Documentation Policy has been reviewed in group supervision to clearly express:
Timelines for initial and subsequent treatment plan reviews
Supervisor responsibilities for monitoring compliance
Disciplinary action for repeated failure to meet documentation standards
Completion Date of Correction:
4/3/2025.
Person Responsible for Oversight:
Clinical Director
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to provide regular and scheduled individual counseling, at least twice weekly, for seven of seven partial hospitalization clients reviewed.
Client #1 was admitted on June 3, 2024, and was discharged on October 9, 2024. The facility only documented one individual counseling session for the weeks of June 9, 2024 through June 15, 2024, August 25, 2024 through August 31, 2024, September 1, 2024 through September 7, 2024, and September 8, 2024 through September 14, 2024.
Client #2 was admitted on September 12, 2024, and was still active at the time of the inspection. The facility failed to document any individual counseling sessions for the weeks of September 22, 2024 through September 28, 2024, and September 29, 2024 through October 5, 2024.
Client #3 was admitted on June 19, 2024, and was discharged on December 16, 2024. The facility only documented one individual counseling session for the weeks of June 30, 2024 through July 06, 2024, July 07, 2024 through July 13, 2024, July 21, 2024 through July 27, 2024, July 28, 2024 through August 3, 2024, August 11, 2024, through August 17, 2024, August 18, 2024 through August 24, 2024, September 1, 2024 through September 7, 2024, September 8, 2024 through September 14, 2024, September 15, 2024 through September 21, 2024, October 13, 2024 through October 19, 2024, November 17, 2024 through November 23, 2024, November 24, 2024 through November 30, 2024, December 1, 2024 through December 7, 2024. Additionally, the facility did not document any individual counseling sessions for the weeks of August 4, 2024 through August 10, 2024, and December 8, 2024 through December 14, 2024.
Client #4 was admitted on November 6, 2024, and was still active at the time of the inspection. The facility only documented one individual counseling session for the week of November 24, 2024, through November 30, 2024.
Client #5 was admitted May 3, 2024, and was discharged on September 23, 2024. The facility only documented one individual counseling session for the weeks of May 5, 2024, through May 11, 2024, May 19, 2024 through May 25, 2024, May 26, 2024 through June 1, 2024, June 2, 2024 through June 8, 2024, June 9, 2024 through June 15, 2024, June 16, 2024 through June 22, 2024, June 23, 2024 through June 29, 2024, July 14, 2024 through July 20, 2024, July 21, 2024 through July 27, 2024, August 11, 2024 through August 17, 2024, and August 25, 2024 through August 31, 2024. Additionally, the facility did not document any individual counseling sessions for the week of September 1, 2024 through September 7, 2024.
Client #6 was admitted on November 19, 2024, was active at the time of the inspection. The facility only documented one individual counseling session for the weeks of December 1, 2024 through December 7, 2024, December 22, 2024 through December 28, 2024, December 29, 2024 through January 4, 2025, January 5, 2025 through January 11, 2025, and January 12, 2025 through January 18, 2025.
Client #7 was admitted on August 19, 2024, and was discharged on December 29, 2024. The facility only documented one individual counseling session for the week of August 25, 2024 through August 31, 2024, September 1, 2024 through September 7, 2024, September 8, 2024 through September 14, 2024, September 15, 2024 through September 21, 2024, September 22, 2024 through September 28, 2024, September 29, 2024 through October 5, 2024, October 27, 2024 through November 2, 2024, November 24, 2024 through November 30, 2024, December 1, 2024 through December 7, 2024, and December 15, 2024 through December 21, 2024. Additionally, the facility did not document any individual counseling sessions for the week of October 06, 2024 through October 12, 2024, October 13, 2024 through October 19, 2024, and October 20, 2024 through October 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Name: Serenity Mountain Recovery Center
Regulatory Citation ? 28 Pa. Code § 709.94(c)(3)(ii)
"Partial hospitalization treatment services shall include individual and group psychotherapy totaling at least 10 full hours per week. Individual psychotherapy shall be provided and documented at least twice weekly."
Deficiency Identified:
During the licensing inspection, it was found that seven of seven client records reviewed from the Partial Hospitalization Program (PHP) did not reflect at least two documented individual counseling sessions per week, as required. Specific weeks and omissions were cited for Clients #1 through #7.
Plan of Correction:
1. Immediate Corrective Action:
A full audit of all PHP client records was conducted within 24 hours of the licensing finding.
Missed or undocumented individual sessions that could be verified through therapist notes or schedules were immediately added to records with appropriate clinical justification.
Clinicians were required to document all past-due notes and provide a rationale for any missed sessions.
2. Clinical Documentation Policy Review:
The Clinical Documentation Policy was revised to include:
Clear expectations for twice-weekly individual sessions reviewed on 3/28/25 & 4/3/2025.
Allowable exceptions (e.g., excused absences, holidays) with required documentation
Weekly verification process by Clinical Director and Clinical Coordinator/Supervisor.
All clinical staff were re-trained on this policy as of 4/3/2025.
3. Schedule Compliance Monitoring:
A PHP Client Session Tracker was implemented via a manual spreadsheet. This tracks weekly individual sessions per client and alerts clinicians/supervisors when sessions are overdue or missing.
The Clinical Director reviews this tracker every Friday to ensure weekly compliance.
4. Staffing and Caseload Adjustments:
Caseloads were reviewed and redistributed to ensure that all counselors have adequate time to meet the twice-weekly individual requirement.
5. Ongoing Quality Assurance and Supervision:
Clinical Director & Clinical Coordinator/Supervisor are required to review five random charts per week to ensure compliance with counseling frequency and documentation standards.
Non-compliance is addressed in weekly clinical supervision sessions and recorded in supervision logs.
6. Accountability and Disciplinary Measures:
A progressive disciplinary policy was reintroduced for consistent failure to meet session and documentation requirements.
Staff failing to meet expectations will receive a written warning after two missed compliance weeks without documented reason.
Preventive Strategy:
A weekly chart audit will be conducted by Clinical Director.
Results of compliance audits will be shared at the monthly clinical team meeting to promote transparency and accountability.
Periodic peer documentation reviews will be implemented to encourage shared learning and improved practice.
Completion Date of Correction:
4/3/2025.
Person Responsible for Oversight:
Clinical Director
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