INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to keep frozen food at or below 0
At the time of the inspection, the main freezer, which is located in the kitchen, had a temperature reading of 20 Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the inspection, maintenance services addressed an issue with the freezer, which was recorded at a temperature of 20°F. Maintenance resolved the problem the same day. Later that day, the temperature dropped to 0°F, and it has remained at or below that level since.
To prevent this issue from recurring, the executive chef will continue to check and record the temperature daily. Additionally, the COO and the Director of Residential Services will conduct daily inspections. Our service providers will also come in as needed to ensure the equipment is functioning properly. The COO is responsible for implementing this plan of correction. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the project failed to document the purpose of the disclosure on a consent to release information form in one of twenty-one client records reviewed.
Client #1 was admitted to the inpatient non-hospital activity on October 7, 2024 and was active at time of inspection. A release of information form to a federal probation and parole office was signed and dated by the client on October 8, 2024; however, the purpose of the disclosure was not included on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 was discharged on November 23, 2024. The release for Client #1 was corrected on November 13th, 2024, and a new release has been added with the purpose of the disclosure. The Director of Care Management will review all releases prior to the client's assignment to a room and will continue to do so on a weekly basis. Additionally, the Clinical Supervisor will audit charts weekly to ensure that the purpose of the disclosure is included on the consent form.
Monthly training sessions will be held regarding the release forms, specifically focusing on the purpose of disclosure. The COO will meet each month with the Clinical Supervisor, Director of Care Management, and Human Resources to ensure compliance with these requirements. This includes verifying that training is completed upon hiring, as well as monthly and annually thereafter. Additionally, the team will assess whether more frequent training is necessary to prevent this issue from recurring. The COO will oversee this entire process.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's January 2024 through November 2024 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident at the facility of a physical assault involving clients on July 1, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There was a misunderstanding between the behavioral health technicians and the previous clinical supervisor concerning the altercation. After reviewing the video evidence, it was determined that there was no physical contact between the clients involved. The previous clinical supervisor has since resigned from Malibu Wellness Ranch prior to the inspection.
The current clinical supervisor will address the importance of clear communication and accurate documentation with all counselors and behavioral health technicians. A training session on proper documentation and incident reporting will take place on or before December 12, 2024. The clinical supervisor will also conduct weekly audits to ensure accurate documentation is maintained. Additionally, the Chief Operating Officer (COO) will meet with the clinical supervisor on a weekly basis to oversee the compliance of proper documentation. The COO is responsible for ensuring ongoing adherence to these standards. |