INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2024 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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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 fire drills from September 2023 through August 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. The last fire drill during sleeping hours was completed on February 28, 2024.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Fire Drill during sleeping hours:
Two sleeping hour fire drills will be scheduled each year
One is scheduled for October 29th, 2024
One will be scheduled for December.
2025 Fire Drill Schedule will include 2 sleeping hour drills 6 months apart.
Monitored and Tracked via TRPA QAPI program. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of fourteen records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #2 was admitted on September 18, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Admissions and Nursing will conduct refresher training on release forms at admission with department staff. Will review documents that are required to be completed at admission. Training attendance will be documented.
For three months, Admissions will review 100% of all admissions to verify compliance for each admission's chart within 48 hours of admission.
Admissions director will audit 10% of all admission charts per month for 3 months to determine compliance scores.
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