INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6 & 7, 2026, 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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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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of thirty-seven records reviewed.
Client #26 was admitted to the partial hospitalization level of care on August 26, 2025, and discharged on September 15, 2025. There was documentation that the facility communicated with a financial institute on September 12, 2025; however, there was no documentation that the facility obtained an informed and voluntary consent for this organization.
Client #27 was admitted to the partial hospitalization level of care on November 15, 2025 and stepped down to the intensive outpatient level of care on December 15, 2025, and remains active at the time of the inspection. There was documentation that the facility communicated with a substance abuse facility on November 19 and December 3, 2025; however, there is no documentation that the facility obtained an informed and voluntary consent for this organization.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the deficiency, the Clinical Supervisor immediately reviewed Client #27's chart. A new Release of Information (ROI) was completed and placed in the record, covering all future contacts with the substance‑use facility and any other external entity.
The ROI includes: (1) the name of the outside facility; (2) a description of the specific information to be released; (3) the purpose of the disclosure; (4) the client's signature and a staff witness signature with dates; and (5) an expiration date. A copy was offered to the client and documented accordingly.
Staff have been instructed that a written consent meeting these elements must be on file before any communication with external providers, agencies, insurers, or financial institutions. Verbal consent alone is no longer accepted.
Client #26 was discharged prior to the inspection. Because the client is no longer in treatment, the facility cannot retroactively obtain consent for the September 12, 2025 communication.
The unauthorized disclosure has been documented in the closed record with an explanation of the regulatory requirement and corrective actions taken. This documentation ensures that, should the record be reviewed again, the deficiency and remediation are evident.
Effective immediately, staff must verify the presence of a valid, complete ROI (including the name of the recipient, specific information to be disclosed, purpose, signatures, and expiration date) before placing any outgoing call or sending information.
The Clinical Supervisor will audit open charts twice weekly for 60 days to confirm that consents are properly completed and filed before any communications. Findings and corrective actions will be documented. Non‑compliance will result in immediate corrective action with the responsible staff member. After 60 days, audits will transition to monthly spot checks.
All clinical and administrative staff will receive training by January 31, 2026 on confidentiality requirements, proper completion of informed consents, and procedures for contacting external entities. This training will be incorporated into orientation for new hires.
The updated process and audit findings will be reviewed in monthly performance‑improvement meetings to ensure sustained compliance and to adjust procedures as needed.
Completion Date: 01/31/2026 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of thirty-seven records reviewed.
Client #30 was admitted to the partial hospitalization level of care on December 27, 2024 and stepped down to the intensive outpatient level of care on January 10, 2025, and discharged on January 24, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a substance abuse facility dated January 21, 2025, was offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client #30 was discharged prior to the inspection. Because the client is no longer in treatment, the facility cannot retroactively offer a copy of the Release of Information form dated January 21, 2025; however, the deficiency has been addressed through immediate corrective action to ensure it does not recur.
Effective immediately, the Clinical Supervisor issued a reminder email to all clinical and administrative staff reinforcing the facility's existing Release of Information (ROI) policy requirements, including that a copy of the signed consent must be offered to the client at the time of completion and documented accordingly, and that a signed copy must be maintained in the client record. Staff were advised that documentation must be completed each time an ROI is created.
The Clinical Supervisor will audit open charts twice weekly for 60 days to confirm that (1) all signed ROIs are filed in the record and (2) documentation reflects that a copy was offered to the client. Audit findings and corrective actions will be documented. Any non-compliance will result in immediate corrective action with the responsible staff member. After 60 days, audits will transition to monthly spot checks.
Training will be held on or before 01/31/2026 with all clinical and administrative staff on confidentiality requirements, proper completion of informed consents, and documentation requirements, including offering the client a copy of the signed ROI. This training will be incorporated into orientation for new hires at time of hire and will occur yearly thereafter for all staff.
The updated process and audit findings will be reviewed in monthly performance-improvement meetings to ensure sustained compliance.
Completion Date: 01/31/2026
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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 client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client and included written documentation of the type and frequency of treatment and rehabilitation services in six out of fourteen applicable client records reviewed.
Client #23 was admitted to the partial hospitalization level of care on November 27, 2025 and discharged on December 11, 2025. A comprehensive treatment plan was developed on December 1, 2025, with no type and frequency identified.
Client #24 was admitted on December 5, 2025 and discharged on December 12, 2025. A comprehensive treatment plan was developed on December 8, 2025, with no type and frequency identified.
Client #25 was admitted on September 29, 2025 and discharged on October 11, 2025. A comprehensive treatment plan was developed on October 2, 2025, with no type and frequency identified.
Client #26 was admitted on August 26, 2025 and discharged on September 15, 2025. A comprehensive treatment plan developed on August 28, 2025, with no type and frequency identified.
Client #27 was admitted to the partial hospitalization level of care on November 15, 2025 and stepped down to intensive outpatient level of care on December 15, 2025, and is still active at the time of the inspection. A comprehensive treatment plan was developed on November 25, 2025, with no type and frequency identified.
Client #31 was admitted to the partial hospitalization level of care on July 31, 2025 and stepped down to the intensive outpatient level of care on September 1, 2025, and discharged on September 30, 2025. A comprehensive treatment plan was developed on August 4, 2025, with no type and frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #23, #24, #25, #26, and #31 were discharged prior to the inspection. Client #27 remained active at the time of the inspection. Upon notification of the deficiency, the Clinical Supervisor immediately reviewed Client #27's chart and updated the comprehensive treatment plan to include written documentation of the required type and frequency of treatment and rehabilitation services for the client's current level of care.
Because Clients #23, #24, #25, #26, and #31 are discharged, the facility cannot retroactively correct the documentation in the record; however, the deficiency has been addressed through corrective action to ensure this does not recur.
Effective immediately, the facility will update the existing Residential, PHP, and IOP comprehensive treatment plan forms on or before 01/31/2026 to ensure the form includes specific language and required fields identifying the type and frequency of services based on the client's current level of care. Staff will be required to review these requirements with the client and obtain appropriate signatures confirming the plan was developed with the client and includes type and frequency as required.
The Clinical Supervisor will audit open charts twice weekly for 60 days to confirm that all comprehensive treatment plans include type and frequency documentation as required. Findings and corrective actions will be documented. Any non-compliance will result in immediate corrective action with the responsible staff member. After 60 days, audits will transition to monthly spot checks.
Training will be held on or before 01/31/2026 with all clinical staff regarding treatment plan requirements, documentation standards, and proper completion of the updated level-specific comprehensive treatment plan forms. This training will be completed at time of hire and will occur yearly thereafter for all staff.
The updated process and audit findings will be reviewed in monthly performance-improvement meetings to ensure sustained compliance.
Completion Date: 01/31/2026 |
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 the client records, the facility failed to ensure that counseling was provided to a client on a regular and scheduled basis to include individual counseling, at least twice weekly in six out of fourteen records reviewed.
Client #20 was admitted to the partial hospitalization level of care on September 3, 2025 and stepped down to the intensive outpatient level of care on October 2, 2025, and was still active at the time of the inspection. The weeks of October 5, 19, 26, November 23, December 14 and 25, 2025 only had one documented individual counseling session.
Client #25 was admitted to the partial hospitalization level of care on September 29, 2025 and discharged on October 11, 2025. The week of October 5, 2025, only had one documented individual counseling session.
Client #26 was admitted to the partial hospitalization level of care on August 26, 2025 and discharged on September 15, 2025. The week of August 31, 2025, only had one documented individual counseling session.
Client #27 was admitted to the partial hospitalization level of care on November 15, 2025 and stepped down to intensive outpatient level of care on December 15, 2025, and is still active at the time of the inspection. The weeks of November 16 and December 7, 2025, only had one documented individual counseling session.
Client #28 was admitted to the partial hospitalization level of care on June 11, 2025 and stepped down to intensive outpatient level of care on July 14, 2025, and discharged on August 12, 2025. The weeks June 30 and July 6, 2025, only had one documented individual counseling session.
Client #31 was admitted to the partial hospitalization level of care on July 31, 2025 and stepped down to the intensive outpatient level of care on September 1, 2025, and discharged on September 30, 2025. The week of August 3, 2025, only had one documented individual counseling session.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clients #25, #26, #28, and #31 were discharged prior to the inspection. Clients #20 and #27 remained active at the time of the inspection. Upon notification of the deficiency, the Clinical Supervisor immediately reviewed the schedules for Clients #20 and #27 and ensured that each client is scheduled and receiving individual counseling sessions consistent with the required frequency within each calendar week (Sunday?Saturday) moving forward. The Clinical Supervisor also reviewed documentation expectations with clinical staff to ensure that individual counseling sessions are properly documented in the record of service and progress notes.
The facility identified that the deficiency occurred because individual counseling sessions were being scheduled and tracked using a rolling seven (7) day period based on admission date, rather than being scheduled and documented based on the required calendar week standard. Effective immediately, clinical scheduling and compliance monitoring will be completed using a calendar week standard to ensure counseling requirements are met each week.
Because Clients #25, #26, #28, and #31 are discharged, the facility cannot retroactively provide additional individual counseling sessions; however, the deficiency has been addressed through corrective action to ensure this does not recur.
Effective immediately, the facility will ensure the following minimum individual counseling requirements are met and documented per calendar week based on level of care:
PHP: at least two (2) individual counseling sessions per calendar week
IOP: at least one (1) individual counseling session per calendar week
The Clinical Supervisor will implement a weekly scheduling review process to verify that each client is scheduled appropriately and that sessions are completed and documented within the calendar week.
The Clinical Supervisor will audit open charts twice weekly for 60 days to confirm that individual counseling is being provided according to level of care requirements and documented appropriately. Findings and corrective actions will be documented. Any non-compliance will result in immediate corrective action with the responsible staff member. After 60 days, audits will transition to monthly spot checks.
Training will be held on or before 01/31/2026 with all clinical staff regarding counseling frequency requirements by level of care, calendar week scheduling expectations, and documentation standards. This training will be completed at time of hire and will occur yearly thereafter for all staff.
The updated process and audit findings will be reviewed in monthly performance-improvement meetings to ensure sustained compliance.
Completion Date: 01/31/2026 |
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 client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client that included written documentation of type and frequency of treatment and rehabilitation services in three out of six applicable client records reviewed.
Client #32 was admitted to the intensive outpatient level of care on December 22, 2025 and is still active at the time of the inspection. A comprehensive treatment plan was developed on December 26, 2025, with no type or frequency identified.
Client #37 was admitted to the intensive outpatient level of care on October 6, 2025 and discharged on October 25, 2025. A comprehensive treatment plan was developed on October 9, 2025, with no type or frequency identified.
Client #38 was admitted to the intensive outpatient level of care on September 1, 2025 and discharged on September 30, 2025. A comprehensive treatment plan was developed on September 5, 2025, with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #32 remained active at the time of the inspection. Clients #37 and #38 were discharged prior to the inspection. Upon notification of the deficiency, the Clinical Supervisor immediately reviewed Client #32's chart and updated the comprehensive treatment plan to include written documentation of the required type and frequency of treatment and rehabilitation services consistent with the client's level of care.
Because Clients #37 and #38 are discharged, the facility cannot retroactively correct the documentation in the record; however, the deficiency has been addressed through corrective action to ensure this does not recur.
Effective immediately, the facility will update the existing IOP comprehensive treatment plan form on or before 01/31/2026 to ensure the form includes specific required fields identifying the type and frequency of treatment and rehabilitation services for the intensive outpatient level of care. Staff will be required to complete these fields and review the plan with the client as part of the treatment planning process.
The Clinical Supervisor will audit open charts twice weekly for 60 days to confirm that IOP treatment plans include the required type and frequency documentation. Findings and corrective actions will be documented. Any non-compliance will result in immediate corrective action with the responsible staff member. After 60 days, audits will transition to monthly spot checks.
Training will be held on or before 01/31/2026 with all clinical staff regarding treatment plan requirements, documentation standards, and proper completion of the IOP comprehensive treatment plan form to ensure type and frequency are consistently documented. This training will be completed at time of hire and will occur yearly thereafter for all staff.
The updated process and audit findings will be reviewed in monthly performance-improvement meetings to ensure sustained compliance.
Completion Date: 01/31/2026 |