INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted July 19-20, 2023, 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.
|
Plan of Correction
|
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
|
Observations
Based on a review of the Staffing Requirements Facilities Summary Report and the client census at the time of the investigation, the facility failed to maintain the client to counselor ratio at or below the 10:1.The Partial Hospitalization Program ratio was 13:1.The facility ratio for this activity was determined by dividing the total number of hours per week devoted to the active D/A clients by the project work week which equals the counselor FTE (full time equivalent). Then the total number of active D/A clients divided by the counselor FTE equals the facility ratio for the activity.18/40 = .45 (FTE); 6/.45 = 13.33. Client to counselor ratio = 13 to 1.
|
Plan of Correction
The clinical director and the chief operating officer are charged with implementation, review, and ratio monitoring. Corrective action will be fully implemented by August 21st, 2023. A counselor who is dedicated to PHP/IOP clients will start on August 21st, 2023. This will keep the client-to-counselor ratio at 10 to 1. A pending staff resignation will necessitate reallocating each staff member's time following the counselor's departure to ensure client to counselor ratio. On 8/18/2023, the COO, clinical supervisor, and Director of Residential services reviewed the formula provided by DDAP for caseload equivalents, and the Project Director will now utilize the formula going forward to appropriately calculate the ratios and mark accordingly. Client to Staff ratios will be in compliance by 8/21/23. Further, the clinical supervisor will prepare an excel sheet with this format and update it weekly to ensure compliance. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
|
Observations
Based on client and staff interviews, and a review of the Employee Handbook on July 19-20, 2023, the facility failed to follow their Rules of Conduct, Code of Ethics, Fraternization, Harassment Policies and didn't follow their disciplinary procedures. The facility's Employee Handbook indicates that fraternization or harassment may result in disciplinary action up to and including early and immediate termination of employment. The facility's Fraternization Policy indicates that no employee shall engage in any social media connection for at least one year after the client's discharge date. The facility's Sexual Harassment Policy "Covers all employees and clients, is against the law, and will not be tolerated. An investigation will begin within 48 hours of reporting. A corrective action plan addressing all parties involved will be created within 7 business days." The Disciplinary Action procedure states that a disciplinary action note will be placed in the employee file. A meeting with management team to determine the status of employment will be held. Employee # 1, who worked in the kitchen, was reported to have been terminated for sexually harassing female clients. Employee # 2, who currently works as a Behavioral Support Technician, was reported to have violated the employee boundaries by contacting a client via social media (no date documented). Employee # 3, who currently works as a Behavioral Support Technician, was reported to have taken pictures of a female client on his personal cell phone (no date documented). Employees # 4 and 5, worked as Behavioral Support Technicians, were reported to have had an inappropriate relationships with clients (no date documented). The COO reported that the employees were terminated on July 18, 2023. However, there was no documentation of the terminations or that the disciplinary action process was followed.
|
Plan of Correction
Foster Hill Wellness COO had a training with the Director of Residential Services regarding documentation regarding all employee's Rules of Conduct, Code of Ethics, Fraternization, and Harassment Policies on 8/1/2023. All investigations will begin within 48 hours of reporting. A corrective action plan addressing all parties involved will be created within 7 business days. The disciplinary action note will be placed in the employee file and a meeting with the management team will occur to determine the status of employment. The Director of Residential Services has updated our "write-up form" for all and any instances. Further, the COO will meet with the Director of Residential Services at our monthly management meeting to ensure all documentation is occurring.
All staff is trained upon hire and every two years regarding Rules of Conduct, Code of Ethics, Fraternization, and Harassment Policies. All current staff will be re trained on or before 8/24/2023. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on a review of client charts, facility policies, and staff and client interviews on July 19-20, 2023, the facility failed to follow their Medication policies and procedures.The facility's Client Medication Policies indicate that clients are to self-administer their own medication. The facility's Self-Administered Medication protocol indicates that all medications are to be self-administered by the client and recorded and signed for by the client and observing staff member. It was reported during interviews that facility staff administer the medication to clients. Chart documentation showed that the facility Behavior Support Technicians, a Counselor Assistant, and a Nursing Aide were the staff administering client medication.This was discussed with facility staff during the investigation.
|
Plan of Correction
On 8/1/2023 the COO and Director of Residential Services met with all BHTs, Nursing aids, and Counselor assistants regarding our self-administration of medication policy. Fosters Hill Wellness's staff are to only observe the client self-administering their medications. Further, the COO will observe weekly to make sure ongoing compliance with this policy. All news staff onboarding will also be trained by the COO regarding this policy to ensure compliance.
|
709.81(a)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
|
Observations
Based on client chart reviews on July 19-20, 2023, and client interviews conducted on July 19, 2023, the facility failed to assure appropriate treatment services based on client's admission criteria. Residential and nonresidential client services were combined. Clients were attending group sessions for partial hospitalization and inpatient nonhospital residential and rehabilitation activities together.
|
Plan of Correction
All PHP/IOP levels of care will be segregated from residential on or before Monday, 8/21/23. The assigned counselors for PHP/IOP will be the designated facilitator. The tentative start date for the PHP/IOP counselor is 8/21/23. The COO will monitor to ensure all groups are segregated appropriately. There will be training regarding this change on or before 8/21/2023.
|
709.82(a) 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:
|
Observations
Based on a review of client charts and facility policies on July 19-20, 2023, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with a client in one of two charts reviewed. The facility's Admission and Treatment Planning policies indicate that the comprehensive treatment plan must be completed and signed by the client within 5 to 7 days of admission.Client #5 was admitted to the partial hospitalization program on 6/16/2023 and was an active client at the time of the investigation. The comprehensive treatment plan should have been completed on or before 6/23/23. The comprehensive treatment plan was completed on 6/27/2023.
|
Plan of Correction
The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance and completed in a timely manner. Documentation that remains out of compliance will result in a write-up for the responsible counselor. There will be training on or before 8/24/2023 will all clinicians regarding timely documentation. The Clinical Supervisor is responsible for ongoing Compliance with this action. |
709.82(a)(1) 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on a review of client charts and facility policies on July 19-20, 2023, the facility failed to include short and long-term goals for treatment as formulated by both staff and client in one of two charts reviewed. Client #4 was admitted to the partial hospitalization program on 7/19/2023 and was an active client at the time of the investigation. The comprehensive treatment plan dated 7/19/23 had no short or long-term goals documented.
|
Plan of Correction
Client # 4's short and long-term goals in the comprehensive treatment plan were completed on 7/19/23. The Clinical Supervisor will conduct training on the Treatment Planning process on or before 8/24/2023. The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance and completed in a timely manner. The Clinical Supervisor is responsible for this action.
|
709.82(d)(2) 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:
(2) Group counseling, at least twice weekly.
|
Observations
Based on a review of client charts on July 19-20, 2023, the facility failed to document that groups were provided at least twice weekly in one of two charts reviewed. Client #5 was admitted to the partial hospitalization program on 6/16/2023 and was an active client at the time of the investigation. There was no documentation of the client attending group counseling between 6/19/23 through 7/9/23.
|
Plan of Correction
All group notes were completed for Client # 5. Client # 5 group notes have been signed off on. They now appear in this client's chart on or before 8/14/2023. The Clinical Supervisor will conduct weekly group note audits and sign off on completed group notes at the time of the audit so that the notes appear in the client's chart immediately. The Clinical Supervisor is responsible for this action.
|
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
|
Observations
Based on client chart reviews on July 19-20, 2023, and client interviews conducted on July 19, 2023, the facility failed to assure appropriate treatment services based on client's admission criteria. Residential and nonresidential client services were combined. Clients were attending group sessions for partial hospitalization and inpatient nonhospital residential and rehabilitation activities together.
|
Plan of Correction
All PHP/IOP levels of care will be segregated from residential on or before 8/21/23. The assigned counselor for PHP/IOP will be the designated facilitator. The COO will monitor to ensure all groups are segregated appropriately. There will be training regarding this change on or before 8/21/2023. This will also be discussed at our monthly management meeting. Ongoing Compliance.
|
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
|
Observations
Based on a review of client charts and facility policies on July 19-20, 2023, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with a client in one of five charts reviewed. The facility's Admission and Treatment Planning policies indicate that the comprehensive treatment plan must be completed and signed by the client within 5 to 7 days of admission.Client #4 was admitted to inpatient services on 6/23/2023 and was an active client at the time of the investigation. The comprehensive treatment plan should have been completed on or before 6/30/2023. The comprehensive treatment plan was completed on 7/5/2023.
|
Plan of Correction
The Clinical Supervisor will conduct training on the Treatment Planning process and Treatment Plan Reviews on or before 8/24/2023. The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance and completed in a timely manner. The Clinical Supervisor is responsible for this action.
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client charts and facility policies on July 19-20, 2023, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 15 days in one of five charts reviewed. The facility's Treatment Planning policy indicates that treatment plan reviews are to be completed every 14 days.Client # 6 was admitted to the inpatient residential level of care on 6/5/23. He was still an active client at the time of the investigation. The last treatment plan review documented was dated 7/1/23. The next treatment plan review should have been completed on or before 7/15/23.
|
Plan of Correction
Client # 6 was discharged on 7/21/23. The Clinical Supervisor will conduct training on the Treatment Planning process and Treatment Plan Reviews on or before 8/24/23. The Clinical Supervisor will complete weekly chart audits to ensure documentation is within compliance and completed in a timely manner. The Clinical Supervisor is responsible for this action.
|
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client charts conducted on July 19-20, 2023, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in two of five charts reviewed. Client #4 was admitted to inpatient services on 6/23/2023 and was an active client at the time of the investigation. The treatment plan dated 7/5/23 indicated the client is to attend group sessions daily. There was no documentation of the client attending group counseling between 7/5/23 through 7/9/23.Client # 6 was admitted to the inpatient services on 6/5/23. He was still an active client at the time of the investigation. The treatment plans dated 6/6/23, 6/17/23 and 7/1/23, indicated that the client was to attend group sessions daily. There was no documentation of the client attending group counseling between 6/6/23 through 6/15/23 and 6/19/23 through 7/9/23.
|
Plan of Correction
All group notes were completed for Client # 6. Client # 6 group notes have been signed off on. They now appear in this client's chart on or before 8/14/2023.
All group notes were completed for Client # 4. Client # 4 group notes have been signed off on. They now appear in this client's chart on or before 8/14/2023. The Clinical Supervisor will conduct weekly group note audits and sign off on completed group notes at the time of the audit so that the notes appear in the client's chart immediately. The Clinical Supervisor is responsible for this action. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client charts on July 19-20, 2023, the facility failed to comply with a plan of correction to assure appropriate treatment services based on client's admission criteria. Residential and nonresidential client services were combined. Clients were attending group sessions for outpatient, partial hospitalization and inpatient non-hospital residential and rehabilitation activities together. This was previously sited on 3/19/21.
|
Plan of Correction
All PHP/IOP levels of care will be segregated from residential. The assigned counselor for PHP/IOP will be the designated facilitator. The COO will monitor to ensure all groups are segregated appropriately. There will be training regarding an update on this policy on or before 8/24/2023. When levels of care are dropped clients are notified and instructed to participate only in their assigned groups as per their level of care. The COO, Clinical Supervisor, and Director of Residential Services will ensure compliance during monthly management meetings and do additional auditing of chart documentation to ensure this error does not continue and will not reoccur at the next licensing inspection.
|