INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20-21, 2021 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #7 and #8 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #7 was hired as a counselor on February 17, 2020 and was due to have the communicable disease trainings no later than February 17, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #8 was hired as a counselor on September 8, 2020 and was due to have the communicable disease trainings no later than September 8, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
HIV training was scheduled and completed for staff on 1/18/2022 and 1/19/2022 to get these trainings completed. HR Manager will monitor all staff trainings on a monthly basis as part of the Quality Assurance Priority Focus Area tracker to ensure all staff on an on going basis remain in compliance with staff trainings. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the December 2020 through December 2021 fire drill logs, the facility failed to conduct unannounced drills during the months of January and May 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill requirements were reviewed with Environment of Care Director on 12/29/2021. Monthly monitoring of fire drill completions have been added to the Quality Assurance Priority Focus Area tracking log for on going monitoring of compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the December 2020 through December 2021 fire drill logs, the facility failed to conduct an overnight fire drill during the month of June 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill requirements were reviewed with Environment of Care Director on 12/29/2021. Monthly monitoring of fire drill completions have been added to the Quality Assurance Priority Focus Area tracking log for on going monitoring of compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing that he/she has the opportunity for reconsideration of a decision to terminate treatment in one out of two applicable records reviewed.Client #14 was admitted on August 5, 2021 and was administratively discharged on August 11, 2021. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Discharge Policy was updated to include the notification of client and reconsideration of decision. Staff training on changes will occur by 2/28/2022. Monitoring of Administrative Discharges has been added to the Quality Assurance Priority Focus Area tracker for on going monitoring. |
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 client records, the facility failed to provide a complete client record, which is to include a discharge summary in the required timeframe of 48 hours, per The Ranch Policy and Procedure, in one out of one applicable records reviewed.Client #7 was admitted on August 15, 2021 and was discharged on August 18, 2021. The discharge summary was completed on September 28, 2021The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained on timelines for documentation by 2/28/2022. On going monitoring of the completion of discharge summaries in a timely manner will occur via the Quality Assurance Priority Focus Area tracker on a monthly basis. |