INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Ranch Pennsylvania 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to include documentation of the written procedures for the staff development program. The finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
TRPA Policy 5.008 Staff Training and Development Program was created. This policy describes the policy for staff training and development and the procedures for completing the annual assessment of staff training needs, the annual evaluation of staff training needs, the overall training plan. This policy designates who is responsible for each component of the staff development program as well as timeframes for completion of each component. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of facility records, the facility failed to document an assessment of staff training needs. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
TRPA Policy 5.008 Staff Training and Development Program was created. This policy describes the policy for staff training and development and the procedures for completing the annual assessment of staff training needs. This policy designates who has oversight of the assessment.
An annual assessment for 2023 was administered to all staff in November 2022.
This assessment of staff training needs will be conducted annually for all staff. New hires must complete an assessment within 30 days of hire. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of facility records, the facility failed to document an overall plan of staff training needs. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
TRPA Policy 5.008 Staff Training and Development Program was created. This policy describes the policy for staff training and development and the procedures for completing the annual overall plan of staff training needs. This policy designates who has oversight of the training plan.
An annual assessment for 2023 was administered to all staff in December 2022 with a due date of December 15, 2022.
The overall training plan will be conducted annually for all staff. New hires must review and sign the annual training plan within 30 days of hire. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of facility records, the facility failed to document an annual evaluation of staff training needs. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
TRPA Policy 5.008 Staff Training and Development Program was created. This policy describes the policy for staff training and development and the procedures for completing the annual evaluation of staff training needs. This policy designates who has oversight of the evaluation.
The annual evaluation of staff training needs for 2023 was completed on November 10, 2022.
The annual evaluation will be conducted annually. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document a training plan for two employees. Employee #2 was hired at the most current position as the Director of Clinical Operations on June 19, 2022. The last training plan was dated February 8, 2021 and there was no current training plan at the time of the inspection. Employee #7 was hired at the most current position as a counselor on July 5, 2022. The last training plan was dated December 13, 2021 and there was no current training plan at the time of the inspection. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
TRPA Policy 5.008 Staff Training and Development Program was created. This policy describes the policy for staff training and development and the procedures for completing individual training plans. This policy designates who has oversight of individual training plans.
Individual training plans for 2023 are currently being reviewed and developed and will be completed no later than January 2023.
Individual training plans will be complete each year. New hires must review and sign the training plan within 30 days of hire. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #4's employee record.Employee #4 was hired as a counselor on February 21, 2017 and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from January 1, 2021 through December 31, 2021. Employee #2's employee record only documented 22.5 hours of annual training for the training year reviewed.The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
TRPA Policy 5.008 Staff Training and Development Program was created. This policy describes the procedures for ensuring counselors complete the annual required 25 clock hours of training and the individual responsible for monitoring training completions. During the annual training plan development, staff and program director will determine additional relevant trainings to be completed in the upcoming year. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights in seven out of seven records reviewed, including that no client shall be deprived of civil rights and liberties. The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/8/2022, the full lost of client rights referenced under 709.30 were added to the Client Handbook. This Handbook is given to each client and is reviewed during orientation. |
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 include documentation of all required client rights in seven out of seven records reviewed, including that the Program will not deny service to any client based on creed, sex, ethnicity, or marital status. The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/8/2022, the full lost of client rights referenced under 709.30 were added to the Client Handbook, including language stating the facility does 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. This Handbook is given to each client and is reviewed during orientation. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of detox client records, the facility failed to document a discharge summary in two out of four applicable records reviewed. Client #2 was admitted on October 1, 2022 and was discharged on October 4, 2022. The client record did not contain documentation of a discharge summary. Client #3 was admitted on May 14, 2022 and was discharged on May 17, 2022. The client record did not contain documentation of a discharge summary. The findings were reviewed with the facility staff during the licensing inspection.This was a repeat citation from the December 21, 2021 licensing inspection.
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Plan of Correction
Timely discharge summary completions has been added to The Ranch Pa's quality assurance and performance improvement program (QAPI) as a priority focus area (PFA) item. Timely completions of discharge summary will be monitored under this program each month to ensure improvement is being made. If poor performance continues, further corrective action plans will be developed. Completion of this item is also tracked daily by the Director of Clinical Operations who sends daily reminders to clinical staff for DC summary completion. A training for clinical staff on timely DC summary completions will be conducted on 12/14/2022. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of residential treatment client records, the facility failed to document type and frequency on the treatment plans in five out of seven client records reviewed.Client #1 was admitted on October 19, 2022 and was still active at the time of the inspection. A treatment plan was completed on October 19, 2022; however there was no type and frequency documented in the record. Client #3 was admitted on October 24, 2022 and was still active at the time of the inspection. A treatment plan was completed on October 24, 2022; however there was no type and frequency documented in the record. Client #4 was admitted on October 9, 2022 and was still active at the time of the inspection. A treatment plan was completed on October 10, 2022; however there was no type and frequency documented in the record. Client #5 was admitted on September 14, 2022 and was discharged on October 12, 2022. A treatment plan was completed on September 16, 2022; however there was no type and frequency documented in the record. Client #7 was admitted on April 7, 2022 and was discharged on May 2, 2022. A treatment plan was completed on April 12, 2022; however there was no type and frequency documented in the record. The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Compliant treatment plan completions with language documenting the type and frequency of treatment on the treatment plan has been added to The Ranch PA's quality assurance and performance improvement program (QAPI) as a priority focus area (PFA) item. Compliant completions of treatment plans will be monitored under this program each month to ensure improvement is being made. If poor performance continues, further corrective action plans will be developed. A training for clinical staff on compliant treatment plan completions will be conducted on 12/14/2022. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 residential treatment client records, the facility failed to document case consultations according to the facility's policy in five out of seven records reviewed. The facility's policy indicated case consultations would be documented on weekly basis. Client #1 was admitted on October 19, 2022 and was still active at the time of the inspection. Client #1 did not have a case consult documented in the record. Client #2 was admitted on October 19, 2022 and was still active at the time of the inspection. Client #2 did not have a case consult documented in the record. Client #3 was admitted on October 24, 2022 and was still active at the time of the inspection. Client #3 did not have a case consult documented in the record. Client #6 was admitted on August 22, 2022 and was discharged on September 20, 2022. Client #6 did not have a case consult documented in the record. Client #7 was admitted on April 7, 2022 and was discharged on May 2, 2022. Client #7 did not have a case consult documented in the record. The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Corporate UR has retrained staff on the expectation of documenting treatment team on a bi-weekly basis. The corporate policy/SOP has been updated to reflect the new timeframe expectation. Additionally, weekly audits of 10% of in house charts will occur to ensure compliance.
The Corporate Director of Utilization Review and the UR Team Managers will conduct the weekly audits. |