INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 8, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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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 partial and outpatient client records, the facility failed to follow its admission policies and procedures. The facility ' s " Exclusionary Criteria " notes one criteria that precludes a client for admission is " (the client) would be better served by a program more appropriate to the individual's diagnosis or condition." The facility's intake documentation indicates that Client #1 should have been referred to a treatment facility/program that could more appropriately meet the individual's diagnosis or condition.Client #1 was admitted on March 10, 2025, to the facility's partial hospitalization level of care then transferred to the outpatient level of care on April 21, 2025, and discharged on June 4, 2025.The client's primary counselor documented the following in the Biopsychosocial Summary completed on March 12, 2025: " due to the complexities of (Client #1 ' s) mental health and cognitive challenges, placement in the Partial Hospitalization Program (PHP,) for drug and alcohol abuse may not be appropriate at this time ... " Additionally, on March 11, 2025, the client's primary counselor completed a Columbia Suicide Risk Assessment. This assessment states the client is " high risk, refer for psychiatric evaluation and stabilization. " Finally, on March 11, 2025, a Safe-T Protocol CSSRS note signed by the client's primary counselor and the facility doctor concluded " pt. minimizes the frequency and intensity of SI. Prior INPT hospitalizations (21) for suicidality. Uses substances to cope with panoply of mental health concerns. A higher level of care is warranted for this client."This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the circumstances related to Client #1's admission and continued participation in services. At the time of admission, the primary counselor documented clinical concerns regarding the complexity of the client's presentation and the appropriateness of placement. The case was subsequently reviewed with the Clinical Supervisor and facility physician, and a clinical determination was made that the client could be appropriately managed within the program with additional oversight and monitoring. However, the updated clinical rationale and supervisory review were not clearly documented in the client record, resulting in the appearance that admission and exclusionary criteria were not followed.
To correct this deficiency, the facility has reinforced that all admission decisions, supervisory consultations, physician reviews, and any changes in clinical judgment must be clearly documented in the client record. Effective immediately, all admissions and clients presenting with complex clinical needs require documented approval by the Clinical Supervisor confirming appropriateness of placement and identifying planned clinical supports.
Clinical staff have been retrained on scope of practice, admission criteria, exclusionary criteria, and documentation standards to ensure that all supervisory determinations and clinical decisions are properly recorded.
Additionally, the facility has implemented a mandatory supervisory case review within 24?48 hours of admission for clients presenting with complex clinical needs. The Clinical Supervisor will conduct monthly audits of new admissions for a period of six (6) months to ensure compliance with admission criteria and documentation requirements. Any identified deficiencies will be addressed through corrective action, additional staff training, and enhanced documentation oversight.
Completion Date: 02/15/2026 |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of partial records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures. The facility's policy and procedures manual states that a case consultation will be completed upon admission and at the time of discharge. Client #1 was admitted on March 10, 2025, and discharged on June 4, 2025. There was one case consultation documented in the client record when the client was admitted to outpatient on April 24, 2025. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility reviewed the documentation for Client #1, which was incomplete and did not fully reflect supervisory review at admission and discharge as required by facility policy. Although the client's case was reviewed with the Clinical Supervisor during the course of treatment, the consultation was not consistently documented in accordance with established procedures. Additionally, required consultation at discharge was not completed in the record.
Effective immediately, the facility will require documented case consultation at admission, at any level-of-care transition, and at discharge for all clients. A standardized case consultation template has been implemented to ensure supervisory review, clinical rationale, and recommendations are clearly recorded in the client record. Clinical staff have received retraining on documentation timelines and the requirement that all supervisory consultations be formally documented.
To ensure ongoing compliance, the Clinical Supervisor will review client charts prior to discharge to confirm that required case consultations have been completed. Monthly chart audits will be conducted for a period of six months to verify compliance with documentation requirements. Any deficiencies identified will result in corrective coaching or additional staff education.
Completion Date: 02/15/26 |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on a review of partial client records, the facility failed to provide a complete client record, which is to include a discharge summary.Client #1 was admitted on March 10, 2025, and discharged on June 4, 2025. There was no discharge summary in the client record to document the client ' s completion of partial services on April 24, 2025. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges that a discharge summary was not completed to document Client #1's completion of partial hospitalization services prior to transition to outpatient care. While the client continued treatment within the organization and a discharge summary was completed at final discharge, documentation specific to the partial level-of-care transition was not entered into the record.
Effective immediately, a discharge summary will be completed for every discharge and for each level-of-care transition to ensure a complete and accurate client record. A standardized discharge summary template has been implemented to ensure all required elements are addressed, including treatment progress, clinical status at discharge, level-of-care changes, referrals, and continuing care recommendations. Clinical staff have been retrained on discharge documentation requirements and timelines.
To prevent recurrence, client charts will not be closed or transitioned between levels of care until required discharge documentation is completed and reviewed by the Clinical Supervisor. Monthly audits of discharged and transitioned records will be conducted for six months to ensure compliance with documentation standards. Any identified deficiencies will be addressed through corrective action and additional training as needed.
Completion Date: 02/15/26 |