INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 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 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from October 2024 through May 2025, the facility failed to ensure that fire drills were conducted unannounced at least once a month.
There was no documentation of a fire drill occurring during the months of October 2024, November 2024, December 2024. January 2025 and February 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility, while licensed, did not admit its first client until March 2025 due to insurance credentialing delays.
To insure compliance with this regulation, the Project Director will conduct an in-service training with Serenity Lodge staff to review and reinforce fire drill protocols. This training will be implemented to ensure that all required fire drills are completed consistently and documented accurately in accordance with agency policy and regulatory standards. The in-service will emphasize staff responsibilities, proper procedures, and the importance of maintaining safety compliance across all shifts.
Project Director will conduct a quarterly review of fire drills to confirm compliance with applicable standards.
This deficiency will be resolved by August 1, 2025,
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from October 2024 through May 2025, the facility failed to ensure that fire drill logs included the date, amount of time it took for evacuation, the exit route used, the number of persons in the facility at the drill, problems encountered, and whether the fire alarm or smoke detector was operative.
The October 2024 through February 2025 fire drill log did not indicate the date, the amount of time it took for evacuation, the exit route used, the number of persons in facility at the time of the drill, problems encountered, and whether fire alarm or snoke detector was operative.
The March 2025 through May 2025 fire drill log did not indicate the exit route used, the number of persons in facility at the time of the drill, problems encountered, and whether fire alarm or snoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has conducted a comprehensive review of the site's current policies and procedures and has developed a revised Fire Drill Log to ensure compliance and staff accessibility. This updated log is now digitally available to all shifts and is designed to align precisely with the fire safety protocols outlined in the organization's policy and procedure manual. The Fire Drill Log will be maintained on a monthly basis, with documentation that reflects all required elements and bullet points as specified in the policy. This measure ensures consistent implementation and accountability across all operational hours.
Project Director will conduct a quarterly review of fire drills to confirm compliance with applicable standards.
This deficiency is considered resolved effective immediately.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on review of fire drill logs from October 2024 through May 2025, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
There was no documentation that a fire alarm or smoke detector was set off during the October 2024 through May 2025 fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, as part of the staff in-service on fire drills, will educate and enforce with staff the necessity to trigger a fire drill by setting of a fire or smoke alarm in the facility. Additionally, the revised Fire Drill Log will also have a specific section to indicate whether a fire/smoke alarm was utilized to conduct the drill. This addition enhances accountability and ensures accurate documentation of fire safety practices. The updated log remains accessible to all shifts and will be maintained monthly, with all entries aligned with the specific requirements outlined in the site's fire safety policy and procedure. This measure supports consistent compliance and reinforces the integrity of emergency preparedness documentation. This deficiency is considered resolved effective with the fire safety in service to be conducted on or before August 1, 2025 |
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 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 in four out of four records reviewed.
Client #1 was admitted to the partial hospitalization level of care on March 18, 2025, and was transferred to the outpatient level of care on May 5, 2025, and is still active in that level of care. An informed and voluntary consent from the client for the funder was not documented in the client record and the facility confirmed billing had occurred.
Client #2 was admitted on April 30, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for the funder was not documented in the client record and the facility confirmed billing had occurred.
Client #3 was admitted to the partial hospitalization level of care on April 22, 2025, and was transferred to the outpatient level of care on May 9, 2025, and is still active in that level of care. An informed and voluntary consent from the client for the funder was not documented in the client record and the facility confirmed billing had occurred.
Client #4 was admitted to the partial hospitalization level of care on May 07, 2025, and was transferred to the outpatient level of care on May 13, 2025, and is still active in that level of care. An informed and voluntary consent from the client for the funder was not documented in the client record and the facility confirmed billing had occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Clinical Director, in coordination with the Intake Specialist, have taken immediate corrective action. All clients have since signed the appropriate release of information authorizing disclosure to their respective billing / funding entities and have been properly informed.
To strengthen compliance and streamline documentation, a dedicated set of Release of Information (ROI) forms specifically for insurance/funding/billing purposes has been created and implemented within the agency's Electronic Medical Records (EMR) system.
Moving forward, the project will ensure that informed and voluntary consent is obtained from each client prior to the disclosure of any information to third parties, including billing agencies. This process will be consistently applied to uphold client confidentiality and ensure full compliance with applicable privacy regulations.
This deficiency is considered completed as of submission.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of four client records reviewed.
Client #4 was admitted to the partial hospitalization level of care on May 07, 2025, and was transferred to the outpatient level of care on May 13, 2025, and is still active in that level of care. A consent form signed and dated May 07, 2025, for a family member, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has reviewed and updated all consent and release forms in the facility's Electronic Medical Record and confirmed all forms now have a required section to confirm that a copy of the consent or release was offered to the client, even if refused.
All staff have been formally notified of this update and that forms will require it to be completed before they can be finalized in the Electronic Medical Record.
This deficiency is considered resolved effective immediately.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they had been notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in four out of four client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has confirmed that the Client Bill of Rights fully lists all non-discriminatory practices and that a signature form acknowledging receipt of these rights has been successfully added to the agency's Electronic Medical Records (EMR) system for all clients to sign during the intake process and in receipt of client handbook.
This integration ensures that all future clients are accurately informed regarding the Client Bill of Rights upon admission and are given the opportunity to review and sign the document as part of the intake process. This measure reinforces the agency's commitment to client rights, transparency, and regulatory compliance.
This deficiency is resolved effective immediately.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in one out of two applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 14 days following admission.
Client #2 was admitted on April 30, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 14, 2025; however, it was not completed until June 11, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Project Director have reviewed this deficiency with clinical staff during an in-service session. The importance and requirement for all chart documentation to be completed timely and within established guidelines was reviewed and affirmed.
Further, Clinical and Project Directors have added treatment plan signature sign offs to an automated Chart Check system in the EMR that allows for a snapshot view of timelines for documentation being met as well as provides clinicians of upcoming deadlines for documentation to prevent future occurrence. This will allow for real-time monitoring and corrections, if needed, to staff documentation performance.
This deficiency is considered resolved effective immediately.
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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 project failed to document two weekly individual counseling sessions in two of two partial hospitalization clients reviewed.
Client #1 was admitted to the partial hospitalization level of care on March 18, 2025 and transferred to a lower level of care on May 05, 2025. The facility only documented one individual counseling session for the week of March 30, 2025 through April 5, 2025.
Client #2 was admitted to the partial hospitalization level of care on April 30, 2025 and was still active at the time of the inspection. The facility only documented one individual counseling session for the weeks of May 4, 2025 through May 10, 2025, May 11, 2025 through May 17, 2025, May 18, 2025 through May 24, 2025 and May 25, 2025 through May 31, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Project Director have reviewed this deficiency and chart documentation with staff.
Clinical staff were viewing the time frame of a "week" based on their work schedule, as opposed to the starting and working forward from the date of admission.
Clinical Director has performed an Inservice with all staff to confirm understanding and enforce adherence to required sessions being performed in required timelines, based on the admission date of each client.
Further, individual session requirements have been added as a reoccurring audit item in the new EMR Chart Check System. This will allow for both clinicians to stay on top of upcoming deadlines for sessions/documentation as well as allow for real time monitoring by the Clinical Director.
This deficiency is resolved effective immediately.
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709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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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 case consultation information within 30 days of admission, in two of two applicable records reviewed.
Client #1 was admitted to the partial hospitalization level of care on March 18, 2025, and was discharged on May 05, 2025. A case consultation was due no later than April 18, 2025, however, there was no documentation of case consultation information in the record.
Client #2 was admitted to the partial hospitalization level of care on April 30, 2025, and was still active at the time of the inspection. A case consultation was due no later than May 30, 2025, however, there was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director had an in-service with clinical staff to review the requirement of Case Consultations being performed and documented in each client's chart within the required time frames.
Each client's chart has been reviewed and updated accordingly with Case Consult documentation to bring them into good standing.
Further, case consult documentation requirements have been added as a reoccurring audit item in the new EMR Chart Check System. This will allow for both clinicians to stay on top of upcoming deadlines for sessions/documentation as well as allow for real time monitoring by the Clinical Director.
This deficiency is resolved effective immediately.
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709.83(a)(10) LICENSURE Client records
709.83. 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 ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary, in three of three applicable records reviewed.
Client # 1 was admitted to the partial hospitalization level of care on March 18, 2025 and discharged on May 05, 2025. The client record did not contain documentation of a discharge summary.
Client #3 was admitted to the partial hospitalization level of care on April 22, 2025 and discharged May 09, 2025. The client record did not contain documentation of a discharge summary.
Client #4 was admitted to the partial hospitalization level of care on May 07, 2025 and discharged on May 13, 2025. The client record did not contain documentation of a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director has conducted an inservice with clinical staff to review and enforce the requirement of documentation, specifically discharge or transfer summaries, as clients are transitioning between levels of care.
All client charts have been reviewed and updated to bring documentation into good standing with requirements.
Further, Transfer and Discharge Summary documentation requirements have been added as a reoccurring audit item in the new EMR Chart Check System. This will allow for both clinicians to stay on top of upcoming deadlines for sessions/documentation as well as allow for real time monitoring by the Clinical Director.
This deficiency is resolved effective immediately.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 14 days following admission.
Client #5 was admitted to the outpatient level of care on May 14, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 28, 2025; however, it was not completed until June 6, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director had an in-service with clinical staff to review the requirement of Comprehensive Treatment Plans being reviewed and documented in each client's chart within the required time frames.
Each client's chart has been reviewed and updated accordingly with regard to Comprehensive Treatment Plan documentation to bring them into good standing.
Further, documentation and review for Comprehensive Treatment Plans requirements have been added as a reoccurring audit item in the new EMR Chart Check System. This will allow for both clinicians to stay on top of upcoming deadlines for sessions/documentation as well as allow for real time monitoring by the Clinical Director.
This deficiency is resolved effective immediately.
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709.93(a)(8) 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:
(8) Case consultation notes.
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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 case consultation information within 30 days of admission, in two of three applicable records reviewed.
Client #4 was admitted to the outpatient level of care on May 9, 2025 and was still active at the time of the inspection. A case consultation was due no later than June 09, 2025, however, there was no documentation of case consultation information in the record.
Client #6 was admitted to the outpatient level of care on May 7, 2025 and was still active at the time of the inspection. A case consultation was due no later than June 7, 2025, however, there was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director had an in-service with clinical staff to review the requirement of Case Consultations being performed and documented in each client's chart within the required time frames.
Each client's chart has been reviewed and updated accordingly with Case Consult documentation to bring them into good standing.
Further, case consult documentation requirements have been added as a reoccurring audit item in the new EMR Chart Check System. This will allow for both clinicians to stay on top of upcoming deadlines for sessions/documentation as well as allow for real time monitoring by the Clinical Director.
This deficiency is resolved effective immediately.
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