INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24-25, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development-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 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure the hot water temperature did not exceed 120 sink in the 1st floor bathroom read at a temperature of 144.5 when tested during licensing inspection.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Director and/or Office Manager will measure the water temperature in all client areas once per month and send to the Property Manager and Director of Recovery Services. Any temperatures in excess of 120 degrees will be immediately reported to property manager and maintenance for adjustment and then temperatures will be remeasured. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of fire extinguishers upon staff employment in one out of five records reviewed.
Employee #1 was hired as project director on November 28, 2025, and was current in that position during the licensing process. Employee #1 was to be instructed in the use of a fire extinguisher upon employment but was not trained until December 22, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will ensure that fire extinguisher and fire exit training is included in onboarding documents for all new employees to be reviewed and signed at the beginning of employment. Director and Office Manager will monitor for compliance through quarterly review of personnel charts. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one out of five records reviewed.
Employee #1 was hired as project director on November 28, 2025 and was current in that position during the licensing process. Employee #1 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until December 22, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will ensure that fire emergency procedure training is included in onboarding documents to include review of transfer of clients and assignment of staff during emergencies. This material will be reviewed with the new employee and their supervisor prior to working in the facility. Director and Office Manager will monitor for compliance through quarterly review of personnel charts. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of client records, the facility failed to record medication errors in the client record in three out of seven records reviewed.
Client #4 was admitted on March 10, 2026, and was discharged May 4, 2026. Client #4 was prescribed Trazadone 100mg and Prazosin HCI 1mg daily; however, there was no documentation that the client received or refused this medication April12, 2026.
Client #6 was admitted on March 30, 2026, and was active at the time of licensing inspection. Client #6 was prescribed Lexapro 10 mg and Nifedipine 90mg er once daily; however, there was no documentation that the client received or refused this medication on May 24, 2026. Additionally, client #6 was prescribed Doxepin HCL 100mg at bedtime however, there was no documentation that the client received or refused this medication on May 15, 2026, May 26, 2026, May 27, 2026, May 28, 2026, and May 30, 2026.
Client #7 was admitted on October 19, 2025, and was active at the time of licensing inspection. Client #7 was prescribed Lexapro 10 mg and Ferosul 325mg once daily; however, there was no documentation that the client received or refused this medication on May 9, 2026, and May 24, 2026. Additionally, client #7 was prescribed Trazodone 15mg at bed; however, there was no documentation that the client received or refused this medication on March 20, 2026, April 6, 2026, 12, 2026, April 13,206, April 29, 2026, April 30, 2026, May 7, 2026, and May 21, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Manager will review medication documentation standards in nursing meeting by 8/15/2026 and follow up with individual nurses as needed in individual supervision. Additionally, Nurse manager will implement a MAR review procedure where MARs are reviewed on each shift to identify and omissions and errors so that documentation errors can be corrected in real time. Nurses will be trained on new MAR procedure by 8/15/26. Director and Nurse manager will monitor monthly for compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and the facility 's policy and procedures manual, the facility failed to provide a complete client record which is to include a case consultation within ninety days of admission, per facility policy, in two out of six applicable records reviewed.
Client #1 was admitted on August 26, 2025, and discharged on June 11, 2026. A case consultation was due by November 26, 2025; however, it did not occur until February 12, 2026.
Client #7 was admitted on October 19, 2025, and was active at the time of licensing. A case consultation was due by January 19, 2026; however, it did not occur until April 2, 2026
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director reviewed with therapists the timelines for clinical documentation including case consultations with 90 days on 7/7 and will provide ongoing reinforcement through monthly supervision. Case consultation dates were added to tracking board to support with adherence to timelines. Director and/or clinical manager will monitor for compliance through monthly chart reviews |