INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2023, 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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704.7(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 four personnel records, the facility failed to ensure two counselors met both the educational and clinical experience qualification requirements for the position.
Employee #2 was promoted to the counselor position on November 16, 2022 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree but not have the required one year of clinical experience.
Employee #3 was promoted to the counselor position on December 6, 2022 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree but not have the required one year of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will be responsible for confirming staffing qualification requirements are met prior to hiring or promoting. Program director also reviewed requirements with administrative staff on 4/4/23.
Although Employee #2 and #3 were promoted to position of counselor they continue to receive close supervision that meets the requirements for the position of counselor assistant. Employee #3 met the requirements for the position of counselor in January 2023 and will remain in the position of counselor. Employee #2 will meet the requirements for the position of counselor on 5/25/2023 and was temporarily moved to the position of counselor assistant on 4/11/2023. |
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 five records reviewed.
Client #1 was admitted on April 6, 2022 and was discharged on January 5, 2023. The record contained documentation that personally identifying information was released to a laboratory on April 13, 2022, with no client signed consent to release information form signed by the client.
Client #3 was admitted on June 24, 2022 and was discharged on January 20, 2023. The record contained documentation that personally identifying information was released to a laboratory on July 8, 2022, and August 15, 2022, with no client signed consent to release information form signed by the client.
Client #4 was admitted on May 4, 2022 and was discharged on September 26, 2022. The record contained documentation that personally identifying information was released to a laboratory on May 11, 2022, and June 29, 2022, with no client signed consent to release information form signed by the client.
Client #6 was admitted on October 14, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to a laboratory on February 13, 2023, with no client signed consent to release information form signed by the client.
Client #7 was admitted on January 4, 2023 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to a laboratory on February 20, 2023, with no client signed consent to release information form signed by the client.
This is a repeat citation from the March 8, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director contacted the laboratory on 03/24/2023 and requested a copy of the QSOA. The request is currently being reviewed and may take up to 30 days. In the meantime, a new QSOA was signed by the program director on 4/6/2023 and sent to the laboratory for signature. Beginning 4/11/23, clients will sign a consent to release information form until a fully executed QSOA is obtained by Serenity.The executed QSOA will be stored electronically and on paper at the facility to ensure it is available during inspections. |
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 ensure that counseling services were provided according to the individual treatment and rehabilitation plans in six of seven records reviewed.
Client #2 was admitted on May 18, 2022 and was discharged on August 18, 2022. The treatment plan completed on May 25, 2022, indicated that the client was to receive 2-4 groups sessions and one individual session per week; however, the record only contained documentation of one group session and no individual sessions the week of June 13, 2022, and no individual session the week of June 27, 2022.
Client #3 was admitted on June 24, 2022 and was discharged on January 20, 2023. The treatment plan completed on August 22, 2022, indicated that the client was to receive 1-2 group sessions per week; however, the record contained no documentation of group sessions during the weeks of October 3, 2022, and October 17, 2022.
Client #4 was admitted on May 4, 2022 and was discharged on September 26, 2022. The treatment plan completed on July 1, 2022, indicated that the client was to receive 2-4 groups sessions and one individual session per week; however, the record contained no documentation of group or individual sessions the week of July 11, 2022, and no group session the week of August 1, 2022.
Client #5 was admitted on September 15, 2022 and was active at the time of the inspection. The treatment plan completed on January 19, 2023, and treatment notes on December 1, 2022, indicated that the client was to receive biweekly individual sessions per month; however, the record contained no documentation of an individual session the week of December 12, 2022.
Client #6 was admitted on October 14, 2022 and was active at the time of the inspection. The treatment plan completed on October 19, 2022, indicated that the client was to receive 2-4 groups sessions and one individual session per week; however, the record only contained documentation of one group session the week of November 14, 2022.
Client #7 was admitted on January 4, 2023 and was active at the time of the inspection. The treatment plan completed on January 11, 2023, indicated that the client was to receive 2-4 groups sessions and one individual session per week; however, the record only contained documentation of one group session the week of February 13, 2023.
This is a repeat citation from the March 8, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sessions were offered in accordance to the individual rehabilitation plan and attended sessions were recorded in the individual client record but some missed sessions were not documented.
Beginning 4/4/23 the facility enabled an EHR report that documents scheduled, missed and attended appointments. This report will be utilized (in addition to the individual client record) to show documentation of sessions are in accordance with the individual rehabilitation plan. Program director will ensure the report is available during inspections. |