INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 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 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
Employee # 1 has been in the position of project director since July 1, 2020. The facility's training year that was reviewed was from January 1, 2024 through December 31, 2024. Employee # 1's employee record only documented 10 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 had 10 hours of outside trainings and was the presenter for 13 additional internal trainings provided by Serenity. The facility was informed that the internal training hours could not be counted for employee #1 due to their role as presenter. Program director reviewed these findings with all staff members on 2/12/2025, and will ensure that all employees have the necessary training hours by completing a biannual review of accrued training hours. The review will be completed by the program director and/or office manager. |
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 of four applicable records reviewed.
Client # 3 was admitted on July 2, 2024 and was discharged on December 23, 2024. A treatment plan update was completed on October 7, 2024, and the next treatment plan update was due no later than December 6, 2024; however, no updates were completed prior to discharge.
Client # 7 was admitted on October 14, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 5, 2024, and the treatment plan update was due no later than January 4, 2025; however, the update was not completed until January 18, 2025.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the identified deficiencies with staff members on 2/12/25. The facility's EHR system was updated to provide automated notifications to the clinical team two weeks prior to treatment plan due dates, with alerts remaining active until updates are completed. The Program Director will conduct regular audits of treatment plan compliance, with support from the Office Manager, who will generate reports for review during biweekly clinical meetings. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information, in four of four applicable records reviewed.
Client # 1 was admitted on August 8, 2024 and was discharged on October 13, 2024. The client record did not contain documentation of follow-up information.
Client # 2 was admitted on July 9, 2024 and was discharged on October 11, 2024. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on July 2, 2024 and was discharged on December 23, 2024. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on September 18, 2024 and was discharged on November 13, 2024. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's policies and procedures were updated to remove the option to document that no follow-up was needed. Staff members are now required to complete follow-ups and the necessary documentation within 30 days of a client's discharge. Additionally, the EHR system was modified to require a follow-up form to be completed after discharge. This requirement, along with a notification to applicable staff, will be automatically triggered upon a client's discharge. The Program Director reviewed the deficiencies, policy and procedure changes, follow-up/documentation requirements, and EHR system updates with staff members on 2/12/25. |