INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 2024 through January 11, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed ensure that all counselors met the appropriate qualifications for the position in one of three applicable personnel records reviewed.Employee #10 was hired as the COO on April 15, 2019. Facility staff confirmed that the employee functions as a counselor on an as-needed basis and there was a progress note, which confirmed the employee facilitated a family counseling session on March 25, 2023. The employee had a certification as a NCAC 1 by a national certification body; however, the certification was not renewed after it expired on July 31, 2020 and the employee does not have a qualifying degree. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Foster Hill Wellness's Clinical Supervisor will ensure that all counselors meet the appropriate qualifications and in an emergency where the original counselor cannot make it the clinical supervisor will step in. The COO has a test scheduled for the end of March through PCB for his NCAC to be renewed. Further, the Director of Residential Services will ensure all certificates are renewed before their expiration date by checking all HR files monthly. The Director of Residential Services will also update an Excel spreadsheet with all staff's expiration dates and will review it weekly.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in three of six records reviewed.The facility policy and procedure manual stated that case consultations are to be completed monthly for clients in the inpatient non-hospital activity. Client # 1 was admitted to the inpatient non-hospital activity on November 7, 2023 and was still active at the time of the inspection. There was documentation of case consultation notes on November 8, 2023; however, there was no documentation of case consultation notes during the month of December 2023.Client # 2 was admitted to the inpatient non-hospital activity on November 21, 2023 and was still active at the time of the inspection. There was documentation of case consultation notes on November 25, 2023; however, there was no documentation of case consultation notes during the month of December 2023.Client # 3 was admitted to the inpatient non-hospital activity on November 25, 2023 and was still active at the time of the inspection. There was documentation of case consultation notes on November 28, 2023; however, there was no documentation of case consultation notes during the month of December 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy located in the facility's policy and procedure manual was out of date. The policy manual was updated on 1/22/24 to include the facility's current policy on case consultation. Case consultations are conducted within 7 days of the client's admission when a client transitions to a different level of care and within 7 days of discharge. Further, the policy and procedure manual will be reviewed yearly to ensure all policies and procedures are up to date. Any changes in our Policy and Procedure manual will be reviewed at our monthly performance improvement meetings to ensure all policies and procedures are up to date.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client records reviewed.Client # 7 was admitted to the inpatient non-hospital activity on July 20, 2023 and was administratively discharged on August 7, 2023. There was documentation in the record that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project and of their right to appeal on August 7, 2023, however, the notification of termination did not include the reason for termination. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/31/24 a new form was created to adequately document and inform a client why they are being involuntarily terminated from treatment and their right to appeal this decision. There will be training held on or before 2/8/24 with all clinicians and support staff regarding the proper use of the "Client Notification of Involuntary Termination" form. Further, these steps and the process will be reiterated during supervision with clinical staff and during our monthly performance improvement meetings with all of Foster Hill Wellness leadership.
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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 client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in three of five applicable client records reviewed. Client # 9 was admitted to the partial hospitalization activity on December 5, 2023 and was still active at the time of the inspection. The individual treatment plan was completed on December 5, 2023 and an update was due no later than January 4, 2024; however, the update was not completed until January 8, 2024.Client # 11 was admitted to the partial hospitalization activity on June 20, 2023 and was discharged on July 24, 2023. The individual treatment plan was completed on June 23, 2023 and an update was due no later than July 23, 2023; however, the update was not completed prior to discharge.Client # 12 was admitted to the partial hospitalization activity on July 6, 2023 and was discharged on August 23, 2023. The individual treatment plan was completed on July 6, 2023 and an update was due no later than August 5, 2023; however, the update was not completed until August 18, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance and completed on time. Documentation that remains out of compliance will result in a write-up for the responsible counselor. There will be training held on or before 2/8/24 with all clinicians regarding timely documentation and compliance. The Clinical Supervisor is responsible for ongoing compliance with this action. Further, this will be reiterated in individual supervision with clinical staff and in our monthly performance improvement meetings with all leadership, to ensure that all documentation is completed promptly.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in four of seven applicable client records reviewed. Client # 11 was admitted to the partial hospitalization activity on June 20, 2023 and was discharged on July 24, 2023. The individual treatment and rehabilitation plan was completed on June 23, 2023 and indicated that the client was to receive 2 individual sessions per week. There was only one individual session completed during the week of June 30, 2023 through July 5, 2023.Client # 12 was admitted to the partial hospitalization activity on July 6, 2023 and was discharged on August 23, 2023. The individual treatment and rehabilitation plan was completed on July 6, 2023 and an update was completed on August 18, 2023. Both plans indicated that the client was to receive 2 individual sessions per week. There was only one individual session completed during the week of July 9, 2023 through July 15, 2023 and during the weeks of July 30, 2023 through August 12, 2012. Client # 13 was admitted to the partial hospitalization activity on March 2, 2023 and was discharged on April 20, 2023. The individual treatment and rehabilitation plan was completed on March 4, 2023 and indicated that the client was to receive 2 individual sessions per week. There was only one individual session completed during the week of April 2, 2023 through April 8, 2023.Client # 14 was admitted to the partial hospitalization activity on June 14, 2023 and was discharged on July 25, 2023. The individual treatment and rehabilitation plan was completed on June 28, 2023 and indicated that the client was to receive 2 individual sessions per week. There were no individual sessions completed during the week of June 25, 2023 through July 1, 2023 and there was only one individual session completed during the weeks of July 2, 2023 through July 22, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client # 14 was discharged prior to our inspection. The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance, completed on time, and counseling services are being provided according to the treatment plan. Documentation that remains out of compliance will result in a write-up for the responsible counselor. There will be training held on or before 2/8/24 with all clinicians regarding timely documentation and compliance. The Clinical Supervisor is responsible for ongoing compliance with this action. Further, this will be reiterated in individual supervision with clinical staff and in our monthly performance improvement meetings with all leadership, to ensure that all documentation is completed in a timely manner.
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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 client records, the facility failed to provide clients admitted to the partial hospitalization program individual counseling services at least twice a week in four of seven applicable client records. Client # 11 was admitted to the partial hospitalization activity on June 20, 2023 and was discharged on July 24, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the week of June 30, 2023 through July 5, 2023.Client # 12 was admitted to the partial hospitalization activity on July 6, 2023 and was discharged on August 23, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the week of July 9, 2023 through July 15, 2023 and during the weeks of July 30, 2023 through August 12, 2012. Client # 13 was admitted to the partial hospitalization activity on March 2, 2023 and was discharged on April 20, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, the week of April 2, 2023 through April 8, 2023.Client # 14 was admitted to the partial hospitalization activity on June 14, 2023 and was discharged on July 25, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the weeks of July 2, 2023 through July 22, 2023. Additionally, there were no individual sessions completed during the week of June 25, 2023 through July 1, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients # 11,12,13, and 14 were discharged prior to our inspection. The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance and completed on time. Documentation that remains out of compliance will result in a write-up for the responsible counselor. There will be training on or before 2/8/24 with all clinicians regarding timely documentation. The Clinical Supervisor is responsible for ongoing compliance with this action. Further, this will be reiterated in individual supervision with clinical staff and in our monthly performance improvement meetings with all leadership, to ensure that all documentation is completed in a timely manner.
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