INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23-24, 2025 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 Outpatient Services 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. There were cameras in the group counseling rooms.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2/24/25 an exception request was submitted by the Executive Director of the program to allow video monitoring of the group rooms.
If the exception is not granted the cameras will be removed from the group rooms immediately following notification of the denied exemption request. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in seven out of seven records reviewed. No staff have received the training.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Operations has created an addendum to the emergency procedures training in order to ensure the training is site specific. The Director of Operations will train all staff with these new procedures during staff training on 3/5/2025.
The Director of Operations will present to the Executive Director at the weekly Operations meeting following the start of a new employee's tenure the signed Emergency Procedures form. |
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 the June-December, 2024 fire drill logs during the inspection, the facility failed to document the number of persons in the facility at the time of the drill June-October and December, 2024. Additionally, the amount of time it took for evacuation in October, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When conducting fire drills the Director of Operations will add the number of people at the facility and the amount of time it took for the evacuation to the fire drill log. The executive director will audit the fire drill logs quarterly to ensure compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from June-December, 2024, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the back exit route.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
When conducting fire drills the Director of Operations will randomly choose a different exit to use when evacuating the facility. These alternating exits will then be documented on the fire drill log. The fire drill log will be audited quarterly by the Executive Director. |
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 a review of fire drill logs from June-December, 2024, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the fire drill procedure the staff member conducting the fire drill will ensure that a smoke detector is set off and then document it as such in the fire drill log. The fire drill log will be audited quarterly by the Executive Director. |
709.82(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the partial hospitalization client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of seven client records reviewed.
Client #2 was admitted on December 30, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 15, 2025 with no type or frequency identified.
Client #3 was admitted on December 18, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 18. 2024 with no type or frequency identified.
Client #4 was admitted on January 2, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 3, 2025 with no type or frequency identified.
Client #6 was admitted on August 9, 2024 and discharged on August 28, 2024. A comprehensive treatment plan was developed on August 13, 2024 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on proper treatment plan development. During this training the staff will be trained to include type and frequency of treatment services, and type of support services provided. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Client #1 was admitted on December 27, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 15, 2025.
Client #2 was admitted on December 30, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 15, 2025.
Client #3 was admitted on December 18, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 18. 2024.
Client #4 was admitted on January 2, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 3, 2025.
Client #5 was admitted on December 26, 2024 and discharged on January 6, 2025. A comprehensive treatment plan was developed on August 13, 2024.
Client #6 was admitted on August 9, 2024 and discharged on August 28, 2024. A comprehensive treatment plan was developed on August 13, 2024.
Client #7 was admitted on December 13, 2024 and discharged on January 6, 2025. A comprehensive treatment plan was developed on December 13, 2024.
These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on proper treatment plan development. During this training the staff will be trained to include type and frequency of treatment services, and type of support services provided. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance. |
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 a review of partial hospitalization client records, the facility failed to provide individual counseling, at least twice weekly, in seven out of seven records.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on the frequency of individual sessions, which is no less than 2 individual sessions weekly for PHP. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance. |
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 partial hospitalization client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 7 days following admission.
Client #1 was admitted on December 27, 2024 and was still active at the time of the inspection. A case consultation was completed on December 27, 2024 and not again until January 15, 2025.
Client #2 was admitted on December 30, 2024 and was still active at the time of the inspection. A case consultation was completed on January 2, 2025 and none has been completed since.
Client #3 was admitted on December 18, 2024 and was still active at the time of the inspection. A case consultation was not completed until January 9, 2025.
Client #4 was admitted on January 2, 2025 and was still active at the time of the inspection. A case consultation was completed on January 3, 2025 and not again until January 13, 2025.
Client #6 was admitted on August 9, 2024 and discharged on August 28, 2024. No case consultations were completed.
These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on the frequency of case consultations, which according to promises policy is 1x weekly for PHP. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document follow up information 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 that the follow up must be completed 7, 30and 90 days following discharge.
Client #6 was admitted on August 9, 2024 and discharged on August 28, 2024. No follow up was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on the frequency of providing follow-up contact post discharge. According to the company policy staff will reach out to the clients post discharge on a 7-day, 30-day, and 90-day interval. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #10 was admitted on January 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 6, 2025 with no type or frequency identified.
Client #11 was admitted on January 13, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 14, 2025 with no type or frequency identified.
Client #13 was admitted on October 28, 2024 and discharged on December 26, 2024. A comprehensive treatment plan was developed on October 28, 2024 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on proper treatment plan development. During this training the staff will be trained to include type and frequency of treatment services, and type of support services provided. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in four out of seven records reviewed.
Client #8 was admitted on December 30, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 30, 2024.
Client #9 was admitted on January 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 15, 2025.
Client #10 was admitted on January 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 6, 2025.
Client #11 was admitted on January 13, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 14, 2025.
These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on proper treatment plan development. During this training the staff will be trained to include type and frequency of treatment services, and type of support services provided. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure 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 in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 7 days following admission.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on the frequency of case consultations, which according to promises policy is 1x weekly for IOP. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7, 30 and 90 days following discharge.
Client #12 was admitted on September 23, 2024 and discharged on December 10, 2024. No follow up was completed.
Client #13 was admitted on October 28, 2024 and was discharged on December 26, 2024. No follow up was completed.
Client #14 was admitted on November 11, 2024 and discharged on November 27, 2024. No follow up was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/5/25 the Executive Director will conduct training with the clinical staff on the frequency of providing follow-up contact post discharge. According to the company policy staff will reach out to the clients post discharge on a 7-day, 30-day, and 90-day interval. The clinical records will be audited by the Executive Director on a quarterly basis in order to ensure compliance.
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