INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2026 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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705.10 (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 facility's June 2025 through April 2026 fire drill logs, the facility failed to ensure their written fire drill log included documentation of the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative.
At the time of the inspection, the February 2026 fire drill log did not include the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director will review protocols for fire drills and fire drill documentation with staff by 7/31/2026 to ensure understanding of the standards.
Director will review fire drill logs monthly to ensure compliance. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client # 4 was admitted on September 24, 2025 and was discharged on January 5, 2026. There was evidence of disclosures to another treatment provider on January 13, 2026; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client # 5 was admitted on September 19, 2025 and was discharged on May 31, 2026. There was evidence of disclosures to another treatment provider on June 8, 2026; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The importance of consent, the process for obtaining consent, and the release of information form will be reviewed with all staff on or before the next staff meeting on August 12, 2026. More Specifically, Director will review with therapists the process of obtaining consent during the aftercare planning process. Director and Assistant Director will monitor for compliance through monthly chart audits. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of the facility policy and procedure manual and client records, the facility failed to document, as part of their intake procedures, a psychosocial evaluation, in four of seven applicable client records reviewed.
The facility policy and procedure manual stated that a psychosocial evaluation will be completed within two weeks of admission.
Client # 1 was admitted on September 16, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed no later than September 30, 2025; however, the evaluation was not completed until October 2, 2025.
Client # 3 was admitted on March 2, 2026 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed no later than March 16, 2026; however, the evaluation was not completed until March 19, 2026.
Client # 4 was admitted on September 24, 2025 and was discharged on January 5, 2026.
The psychosocial evaluation was due to be completed no later than October 8, 2025; however, the evaluation was not completed until October 16, 2025.
Client # 5 was admitted on September 19, 2025 and was discharged on May 31, 2026.
The psychosocial evaluation was due to be completed no later than October 3, 2025; however, the evaluation was not completed until October 6, 2025.
This is a repeat citation from the June 18, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director reviewed timelines for documentation with program therapists on 7/7 including the standard for biopsychosocial assessments to be completed within 14 days of admission. Director and Clinical Manager will continue to reinforce timelines during monthly supervision and will utilize monthly audits to ensure 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:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client, per facility policy, in four of seven applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within twenty-one days of admission.
Client # 1 was admitted on September 16, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than October 7, 2025; however, the treatment plan was not completed until October 16, 2025.
Client # 4 was admitted on September 24, 2025 and was discharged on January 5, 2026. The individual treatment and rehabilitation plan was due to be completed no later than October 15, 2025; however, the treatment plan was not completed until November 4, 2025.
Client # 5 was admitted on September 19, 2025 and was discharged on May 31, 2026. The individual treatment and rehabilitation plan was due to be completed no later than October 10, 2025; however, the treatment plan was not completed until February 10, 2026.
Client # 7 was admitted on August 20, 2026 and was discharged on September 15, 2026. The individual treatment and rehabilitation plan was due to be completed no later than September10, 2025; however, the treatment plan was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director reviewed timelines for documentation with therapists on 7/7 including the standard that initial treatment plans are completed within 21 days of admission. This will be reinforced by Director and Clinical Manager through monthly individual supervision. Director and Clinical Manager will also monitor for compliance through monthly chart audits. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client # 1 was admitted on September 16, 2025 and was still active at the time of the inspection. The individual treatment plan was completed on October 16, 2025; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client # 2 was admitted on March 9, 2026 and was still active at the time of the inspection. The individual treatment plan was completed on March 28, 2026; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
Client # 4 was admitted on September 24, 2025 and was discharged on January 5, 2026. The individual treatment plan was completed on November 4, 2025; however, the plan did not include documentation of the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director reviewed the need for type and frequency in individual treatment plans with program therapists on 7/7 and additional training will be offered to the therapists individually by 7/31 to support their understanding and application. Director and/or Clinical manager will review all treatment plans submitted to ensure compliance with the standard. |