This report is a result of an off-site complaint and unusual incident investigation conducted on October 29, 2025, through November 5, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint and unusual incident 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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Observations
Based on a review of the client record, along with the Reduce the Risk for Suicide/Suicide Risk Identifiers policy, the facility failed to adhere to the written procedures for the Risk for Suicide/Suicide Risk Identifiers policy.
Per the Risk for Suicide/Suicide Risk Identifiers policy, upon admission, every client has the minimum of a Columbia screen. If the client scores high on the screen, the C-SSRS is then completed by a licensed professional. If a client is a high risk, a safety plan is created by a licensed professional. Then the licensed professional alerts staff. The MD & licensed professional will then place the high-risk client on a 1:1 until the client can be sent to the hospital.
Client # 1 was admitted on October 2, 2025, and discharged on October 11, 2025. The Suicide Risk Assessment dated October 6, 2025, was not scored as per the scoring directions located on the risk assessment form. As per the scoring the directions, this client should have been deemed high-risk, and procedures should have been followed for a high-risk score.
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Plan of Correction
Client #1 was admitted on October 2, 2025, and discharged on October 11, 2025. The Suicide Risk Assessment dated October 6, 2025, was not scored according to the scoring directions outlined on the assessment form. To prevent future scoring errors, the facility implemented a unified Suicide Risk Assessment form within the electronic medical record (EMR). This revised form:
Integrates all required C-SSRS screening questions;
Automatically calculates the risk level (low, moderate, or high) based on responses;
Automatically expands into the full SAFE-T assessment when a screening question is positive;
Clearly displays required interventions corresponding to each risk category;
Automatically assigns "High Risk" when questions 4 or 5 are answered "yes," including mandatory one-to-one supervision and prompts for transfer to a higher level of care;
Requires documentation of both the risk level and a completed safety plan before the assessment can be finalized.
These systemic EMR updates eliminate manual scoring errors and ensure that all required follow-up steps are clearly displayed and completed. This improvement was completed as of October 22, 2025.
The Clinical Supervisor reviewed the facility's Risk for Suicide/Suicide Risk Identifiers policy and confirmed that it aligns with national suicide-prevention standards and includes all required components. Because the policy was already adequate, no revisions were necessary. Corrective efforts focused on reinforcing expectations through staff education and improved documentation practices.
On October 28, 2025, a licensed clinical social worker provided training to all clinicians, nursing staff, the Nursing Director, Clinical Supervisor, and leadership team. The session covered:
Proper administration of the C-SSRS and the SAFE-T five-step framework;
How to use and interpret the EMR's automated risk-level outputs;
Documentation requirements for risk level and safety planning;
Regulatory requirements under 28 Pa. Code §709.24.
Staff were provided SAFE-T reference materials, and competency checks were completed. Current suicide-risk training has been updated to include the new EMR-based C-SSRS form and is now incorporated into new-hire orientation and annual refresher training. A facility-wide training session with an Assistant Professor of Psychiatry and Deputy Director for Training & Implementation from The Columbia Lighthouse Project is scheduled for November 20, 2025. This session will reinforce best-practice administration of the C-SSRS, SAFE-T, and required documentation standards.
The Clinical Supervisor will audit 100% of all suicide risk assessments monthly from December 2025 through February 2026. Audits will verify:
C-SSRS completion at admission;
Accurate scoring and appropriate risk-level documentation;
Completion of safety plans and all required high-risk interventions;
Documentation of supervisory review for high-risk cases.
Audit results will be reviewed by the Clinical Supervisor and discussed at monthly PI meetings. Any deficiencies will result in immediate retraining or reinforcement of procedures. After the facility achieves ≥95% compliance for three consecutive months, audits will transition to a quarterly schedule. Additionally, the leadership team will conduct weekly reviews of all suicide risk assessments to ensure scoring accuracy and consistent follow-up.
Completion Date: Ongoing; monthly audits begin December 2025.
The Program Director will oversee implementation of the Plan of Correction (POC) and ongoing monitoring. The Medical Director and Clinical Director will provide clinical oversight, verify scoring accuracy, and ensure proper safety-plan procedures. All staff are responsible for following the updated suicide-risk assessment procedures.
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