INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 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 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 #7 was hired as a counselor on January 15, 2024. His trainings were due no later than January 15, 2025; however, none was completed.
Employee #8 was hired as a counselor on December 4, 2023. Her trainings were due no later than December 4, 2024; however, none was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. An employee work group has been established to develop a protocol to ensure with all employee training requirements, per position and employment tenure, are within compliance.
2. An HIV/AIDS and STD/TB training has been developed internally which will be utilized to ensure compliance. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 October, 2024-October, 2025 fire drill logs during the inspection, the facility failed to document whether the fire alarm or smoke detector was operative. Additionally, the logs did not document the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The form used for monthly fire drills was edited on the day of the inspection with additional entries for documenting that the fire alarm and smoke detectors were operative and the number of persons in the facility at the time of the drill. This form will be used to document fire drills going forward, beginning in November 2025.
The Director of Business Operations is responsible for oversight compliance.
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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 drill logs from October, 2024 through October, 2025 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed only on September 10, 2025.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the September 25, 2024 licensing inspection.
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Plan of Correction
Response: A fire drill "schedule" has been created for 2026, with January and July designated for "sleeping hours" fire drills. The Director of Business Operations is responsible for oversight compliance. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of inpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7-, 30-, and 60-days following discharge.
Client #12 was admitted on July 25, 2025 and discharged on July 29, 2025. A 30 day follow up was due no later than August 28, 2025; however, it was not completed until October 27, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review follow up contacts with responsible employee on a monthly basis to ensure compliance with facility policy and timeframes. Available reports will allow for comprehensive and timely review of compliance status. |