INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD - Womanspace, 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, conducted between 1:00 PM and 1:30 PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The client bathrooms on the second floor and the third floor had what appeared to be mold around the edges of the showers. Additionally, the client bathroom on the second floor had a loose shower drain cover and what appeared to be mold around the drain.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Life Skills Professional staff assisted residents with cleaning the bathrooms on 7/20/2023.
Property Manager will inspect the property and all bathrooms by August 30th to determine if additional mold remediation is needed. If necessary, work will be completed by an outside contractor by 9/30/2023
Maintenance company was contacted to evaluate bathrooms and to re-caulk around the bathroom tubs and to re-intsall drain cover. Work was completed on 8/09/2023 |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide a client the opportunity to request reconsideration of a decision to terminate treatment in one of one applicable client records reviewed.
Client #4 was admitted on February 10, 2023 and was involuntarily discharged on July 5, 2023. There was no documentation in the record that the client was afforded an opportunity to request the reconsideration of being involuntarily discharged.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All Staff will utilize the existing involuntary termination form without amendment that indicates an opportunity to appeal.
Clinical and Administrative staff that are responsible for administering the involuntary termination form were trained in person's legal right to appeal the involuntary termination decision on 7/18/23 and this will be monitored in cases of administrative discharge by the program director moving forward. |