INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26-27, 2026, 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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704.7(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 ensure that one counselor met the educational qualifications for the position in one of six applicable records reviewed. Employee # 5 was hired as a counselor assistant on February 19, 2025 and then promoted to counselor on February 19, 2026 and was current in that position at the time of the licensing inspection. Employee #5 does not possess a qualifying degree from an accredited college, nor a full certification as an addiction counselor by a statewide certification body to meet the qualifications to be promoted to a counselor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:L0037
Facility Name: Serenity Mountain Recovery Center
Facility License number: 647023
Correction due date: 4/7/2026
Submitted by: Clinical Director
Regulatory citation - 28 PA Code 704.7 (b)
"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."
Deficiency identified:
"Based on a review of personnel records, the facility failed to ensure that one counselor met the educational qualifications for the position in one of six applicable records reviewed.
Employee # 5 was hired as a counselor assistant on February 19, 2025, and then promoted to counselor on February 19, 2026, and was current in that position at the time of the licensing inspection. Employee #5 does not possess a qualifying degree from an accredited college, nor a full certification as an addiction counselor by a statewide certification body to meet the qualifications to be promoted to a counselor. "
Plan of Correction:
1. Policy Implementation: Credential verification process. All counselors' credentials will be identified prior to hire then biannually thereafter (January and June of each year. Verification will include certification and licensure status in compliance with the DDAP staffing regulations.
Employee #5 has been changed from counselor-to-counselor assistant to which she meets counselor assistant qualifications.
All supervisors have completed a refresher training on DDAP standards for Counselor Assistant supervision, documentation and responsibilities.
Each counselor assistant is assigned a designated clinical supervisor. Clinical supervisor will maintain a credentialing tracking system for counselor assistants.
Documentation process:
The clinical Supervisor will maintain a tracking log both electronic and manual monitoring counselor assistant qualifications according to DDAP regulations. Clinical director will educate all staff on qualifications for counselor assistant.
Completion Date of Correction: 4/7/2026
Person responsible for oversite:
Clinical Director |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the facility, in one of one applicable record reviewed.Client # 3 was admitted to the partial hospitalization program on July 8, 2025 and was involuntarily discharged on November 5, 2025. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate client ' s treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction : L0333
Facility Name: Serenity Mountain REcovery Center
Facility License number: 647023
Correction due date: 4/7/2026
Submitted by: clinical director
Regulatory citation: 28 PA Code §709.33
" Notification of termination. (a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination."
Deficiency identified:
"Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in one of two applicable records reviewed.
Client # 8 was admitted to the outpatient program on December 29, 2025 and was active at the time of licensing inspection. The individual treatment and rehabilitation plan completed on December 31, 2025, indicated the client was to receive one individual counseling session per week; however, no individual session was documented for the week of January 5, 2026."
Plan of Correction:
Implementation of standardized Termination of Services form.
A formal written letter has been created and implemented by leadership to outline date of termination, reason and appeal process for client's being behaviorally discharged.
Staff was trained on process for discharge, policy and completion of Termination of Services form on EMR.
Clinical supervisor is responsible for oversight of training to ensure that all documentation is completed appropriately.
Completion date of Correction: 4/7/2026
Person responsible for oversite:
Clinical Director |
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 plan in one of two applicable records reviewed.Client # 8 was admitted to the outpatient program on December 29, 2025 and was active at the time of licensing inspection. The individual treatment and rehabilitation plan completed on December 31, 2025, indicated the client was to receive one individual counseling session per week; however, no individual session was documented for the week of January 5, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: L1885
Facility Name: Serenity Mountain Recovery Center
Facility License number: 647023
Correction due date: 4/7/2026
Submitted by: clinical director
Regulatory citation: 28 PA Code §709.92
"709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan."
Deficiency identified:
1). "Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in one of two applicable records reviewed.
2). Client # 8 was admitted to the outpatient program on December 29, 2025 and was active at the time of licensing inspection. The individual treatment and rehabilitation plan completed on December 31, 2025, indicated the client was to receive one individual counseling session per week; however, no individual session was documented for the week of January 5, 2026."
Plan of Correction:
1) Clinical supervisor will implement an electronic tracking system to monitor the completion of the weekly sessions according to level of care. Education and training for all counselors determining the amount and time frames for notes entered into EMR on a weekly basis for all levels of care.
2) Clinical supervisor will implement an electronic tracking system to monitor all of care transitions to ensure proper documentation is completed. Will implement a new policy stating immediate treatment plan review update upon any level of care change. Education and training for all counselors determining the amount and time frames for notes entered into EMR on a weekly basis for all levels of care.
Completion date of Corrections: 4/7/2026
Person responsible for oversite:
Clinical Director
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