INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employee #5 was hired as a counselor on October 21, 2024. Her training was due no later than October 21, 2025; however, none was completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A work group has been formed by the Facility Director to develop a compliance protocol to ensure that all employee training requirements are met within specified timeframes, incorporating position and timeframe requirements. Training compliance will be reviewed on a monthly basis by the Executive Director, Facility Director, and Human Resources.
An HIV/Aids and STD/TB training has been internally developed. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #3 was hired as a counselor on December 4, 2023 and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from January 1, 2024 through December 31, 2024. Employee # 3 ' s record only document 4.5 hours of training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A work group has been formed by the Facility Director to develop a compliance protocol to ensure that all employee training requirements are met within specified timeframes, incorporating position and timeframe requirements. Training compliance will be reviewed on a quarterly basis by the Executive Director, Facility Director, and Human Resources. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher in group room #3 was last inspected October, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will be responsible to ensure that fire extinguishers are inspected and approved annually by fire extinguisher company. This inspection will be reviewed and audited by the Executive Director. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from January - October 2024, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of September, 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills will be conducted monthly by the Director of Operations or designated staff member and he 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 and reviewed during Program Leadership meetings.
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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 January-October, 2024 fire drill logs during the inspection, the facility failed to document whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 23, 2025 licensing inspection.
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Plan of Correction
During the fire drill procedure the Director of Operations will will ensure that a smoke detector is set off and then document as such in the fire drill log. The fire drill log will be audited monthly by the Executive Director and reviewed during Program Leadership meetings. |
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 January-October, 2025, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same exit route in eight of ten drills reviewed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 23, 2025 licensing inspection.
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Plan of Correction
Fire drills will be conducted monthly by the Director of Operations or designated staff member and he 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 monthly by the Executive Director and reviewed during Program Leadership meetings. |
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 partial hospitalization client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #9 was admitted on October 6, 2025 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 12/21/25 the Clinical Director will conduct a training with the clinical staff on the importance of adding a financial disclosure for to the client chart at admission. The clinical records will be audited by the Executive Director on a monthly basis in order to ensure compliance. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of partial hospitalization client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of client in one out of seven records reviewed.
Client #8 was admitted on October 6, 2025 and was still active at the time of the inspection. A release of information dated October 6, 2025 to a funding source was not signed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/21/25 the Clinical Director will conduct a training with the clinical staff on the importance of completing all release of information forms included mut not limited to the release of information for the funding/insurance source. The clinical records will be audited by the executive director on a monthly basis in order to ensure compliance. |
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 outpatient client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in four out of seven outpatient client records reviewed.
Client #1 was admitted on October 13, 2025 and was still active at the time of the inspection. A release of information form for a funding source dated October 23, 2025 did not have documentation that the client was offered a copy of the consent form.
Client #2 was admitted on October 16, 2025 and was still active at the time of the inspection. A release of information form for a funding source dated October 21, 2025 did not have documentation that the client was offered a copy of the consent form.
Client #3 was admitted on September 29, 2025 and was still active at the time of the inspection. A release of information form for a funding source dated September 29, 2025 did not have documentation that the client was offered a copy of the consent form.
Client #4 was admitted on September 29, 2025 and was still active at the time of the inspection. A release of information form for a funding source dated September 22,2025 did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 12/21/25 the Clinical Director will conduct a training with the clinical staff on the importance of offering the client a copy of their informed consent forms and identifying weather the client has accepted or declined the copy. The clinical records will be audited by the Executive Director on a monthly basis in order to ensure compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the timeframe established by the facilities policy and procedure manual in three out of seven records reviewed. The facility's policy and procedures manual states that treatment plan updates must be completed every 10 days.
Client #12 was admitted on June 20, 2025 and was discharged on July 28, 2025. A comprehensive treatment plan was completed on June 20, 2025 and an update was due no later than June 30, 2025; however, it was not completed until July 8, 2025.
Client #13 was admitted on May 2, 2025 and was discharged on June 13, 2025. A comprehensive treatment plan was completed on May 2, 2025 and an update was due no later than May 12, 2025; however, it was not completed until June 6, 2025.
Client #14 was admitted on July 3, 2025 and was discharged on July 24, 2025. A comprehensive treatment plan was completed on July 7, 2025 and an update was due no later July 17, 2025; however, it was not completed until July 24, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 12/21/25 the Clinical Director will conduct a training with the clinical staff on the importance and state regulation of reviewing and updating the clinical treatment plan every 10 days for PHP according to company policy. This review and update will then be presented to the treatment team in the clinical team meeting. The clinical records will be audited by the Executive Director on a monthly basis in order to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the timeframe established by the facilities policy and procedure manual in three out of six records reviewed. The facility's policy and procedures manual states that treatment plan updates must be completed every 14 days.
Client #1 was admitted on October 13, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 13, 2025 and an update was due no later than October 27, 2025; however, none was completed.
Client #3 was admitted on September 29, 2025 and was still active at the time of the inspection. A treatment plan update was completed on October 8, 2025 and an update was due no later than October 22, 2025; however, it was not completed until October 30, 2025.
Client #5 was admitted on May 27, 2025 and was discharged on July 11, 2025. A comprehensive treatment plan was completed on May 28, 2025 and an update was due no later June 11, 2025; however, it was not completed until June 27, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 12/21/25 the clinical director will conduct a training with the clinical staff on the importance and state regulation of reviewing and updating the clinical treatment plan every 14 days for IOP according to company policy. This review and update will then be presented to the treatment team in the clinical team meeting. The clinical records will be audited by the Executive Director on a monthly basis in order to ensure compliance. |