INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 27-28, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Foster Hill Wellness, LLC dba Malibu Wellness Ranch was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
During a complaint investigation conducted on May 27-28, 2026, it was discovered that the facility failed to ensure the hot water temperature does not exceed 120 F. The water temperature in the bathroom sink of the Administration Cabin was 143 F.
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Plan of Correction
The facility immediately adjusted the thermostat at the main intake water source to ensure hot water temperatures do not exceed 120F.
To prevent recurrence, the facility has implemented a routine water temperature monitoring process. A designated BHT will conduct regular water temperature checks of all client and staff accessible hot water sources. Any identified variances will be corrected immediately.
The COO will monitor on an ongoing basis to ensure continued compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of residential client records, the facility failed to adhere to its rounding procedure which requires documented observation of clients every sixty minutes for the entire twenty-four-hour period.
Client #5 was admitted on April 26, 2026, and was discharged on April 27, 2026. The rounding record indicates that on April 27, 2026, the client was observed at 12:18 am and the next observation was to occur no later than 1:18 am; however, the next observation was documented at 2:11 am.
Additionally, the facility failed to adhere to its grievance procedure which is to review client grievances within a day of receipt. DDAP staff reviewed the facility ' s grievance folder. A grievance dated April 22, 2026, had been submitted by a client but there was no documentation that the facility had responded to this complaint as of the date of the onsite investigation conducted on May 27-28, 2026.
This finding was reviewed with the facility staff during the complaint investigation.
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Plan of Correction
Upon identification of the deficiency, the facility conducted an immediate review of client observation documentation and grievance management procedures. Although surveillance footage reviewed by the West Fall Police Department confirmed that required client observations were completed, the EMR system did not accurately reflect all observations performed. Staff were immediately re-educated on the facility's policy requiring client observations to be documented at least every 60 minutes and on the importance of timely accurate documentation.
Effective, 06/15/2026, the BHT Supervisor reviews all observation logs at the end of each shift to verify compliance with observation requirements and documentation standards. Any discrepancies identified are addressed immediately through corrective action, staff coaching, and additional training as needed. The COO will review identified issues to ensure ongoing compliance and accountability.
Additionally, the facility reviewed its grievance process and the Chief Accountability Officer and COO will be responsible to review, investigate, and respond to all grievances within 24 hours of receipt in accordance with facility policy.
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709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of employee records and the facility policy and procedures manual, the facility failed to have written job descriptions for project positions.
Employee # 1 was hired on February 16, 2020, as a Behavioral Health Technician. At the time of this complaint investigation, this employee was the Director of Residential Services. There was no documentation of a written job description for the Director of Residential Services.
Employee # 2 was hired on March 15, 2026, as the Chief Accountability Officer. There was no documentation of a written job description for the Chief Accountability Officer.
Employee # 3 was hired on September 1, 2025, as a Behavioral Health Technician. At the time of this complaint investigation, this employee was the Human Resources Coordinator. There was no documentation of a written job description for the Human Resources Coordinator.
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Plan of Correction
The facility has developed and implemented written job descriptions for all identified positions. A comprehensive audit of all personnel files will be completed by 07/15/2026, to ensure that current job descriptions are present, accurate, and reflective of each employee's assigned duties and responsibilities.
The Human Resources Department will utilize a personnel file audit checklist to verify compliance with personnel record requirements and ensure that all future position changes, promotions, and new hires have an updated job description placed in the employee's personnel file at the time of the change or hire. Any deficiencies identified during the audit will be corrected immediately.
The Human Resources Coordinator will conduct quarterly personal file reviews to monitor ongoing compliance and ensure all required documentation remains current and complete. |
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 client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual.
Client #8 was admitted on April 27, 2026, and was discharged on May 2, 2026. A case consultation was completed on April 28, 2026; however, it only noted the presence of one person participating in the consultation.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The facility has reviewed and revised its case consultation process to ensure compliance with facility policy and regulatory requirements. All clinical staff have been re-educated on the requirements for conducting and documenting case consultations, including documenting all required participants and ensuring multidisciplinary involvement.
The Clinical Director and/or Physician will review all case consultations during weekly audits to verify compliance with documentation standards. Any deficiencies identified will be addressed immediately through corrective coaching and retraining. In addition, the COO will be notified and will monitor corrective actions to ensure sustained compliance. |
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 outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual.
Client #6 was admitted on April 7, 2026, and was discharged on May 2, 2026. A case consultation was completed on April 29, 2026; however, it only noted the presence of one person participating in the consultation.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The facility has reviewed and revised its case consultation process to ensure compliance with facility policy and regulatory requirements. All clinical staff have been re-educated on the requirements for conducting and documenting case consultations, including documenting all required participants and ensuring multidisciplinary involvement.
The Clinical Director and/or Physician will review all case consultations during weekly audits to verify compliance with documentation standards. Any deficiencies identified will be addressed immediately through corrective coaching and retraining. In addition, the COO will be notified and will monitor corrective actions to ensure sustained compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of outpatient client records, the facility failed to provide a complete client record, which is to include an aftercare plan.
Client #6 was admitted on April 7, 2026, and was discharged on May 2, 2026. There was no documented aftercare plan in the client record.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The facility has reviewed the identified deficiency and has re-educated all clinical staff on discharge documentation requirements, including the completion and inclusion of an individualized aftercare plan in the client record prior to discharge.
The Clinical Supervisor will conduct weekly audits of discharged client records to verify that aftercare plans are completed, documented, and included in the clinical record prior to discharge. Any identified deficiencies will be corrected immediately and addressed through staff coaching and retraining as needed.
The COO will be notified of any findings of noncompliance and will monitor corrective actions to ensure sustained adherence to facility policy and documentation standards.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of outpatient client records, the facility failed to provide a complete client record, which is to include a discharge summary.
Client #6 was admitted on April 7, 2026, and was discharged on May 2, 2026. There was no documented discharge summary in the client record.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
The facility has reviewed the identified deficiency and has re-educated all clinical staff on discharge documentation requirements, including the completion of a discharge summary.
The Clinical Supervisor will conduct weekly audits of discharged client records to verify that discharge summaries are completed and signed in accordance with facility policy and regulatory requirements. Any identified deficiencies will be corrected immediately and addressed through staff coaching and retraining as needed.
The COO will be notified of any findings of noncompliance and will monitor corrective actions to ensure sustained adherence to facility policy and documentation standards.
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