INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2025 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure cold food was kept at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
At the time of the inspection, conducted at approximately 11:30 am, the freezer, located in the second-floor hallway, had a registered temperature of 10 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 7/11/2025, refrigerator will remain locked to ensure that the temperature dials support a temperature of below 40* in the refrigerator. Staff will check the temperature of the refrigerator and freezer and record the temperature on the temperature log twice daily and report any deviations in real time to the office manager or director for service. Office manager and Director will monitor compliance through weekly checks of temperature log. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on consent to release information forms in two of seven client records reviewed.
Client # 1 was admitted on March 13, 2025 and was active at the time of inspection. A release of information form, signed and dated by the client on March 13, 2025, indicated the name of the person to whom disclosure would be made to as "Probation/Parole", which is not a specific person, agency, or organization.
Client # 7 was admitted on March 20, 2025 and was discharged on May 2, 2025. A release of information form, signed and dated by the client on March 20, 2025, indicated the name of the person to whom disclosure would be made to as "Probation/Parole", which is not a specific person, agency, or organization.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The generic Probation and Parole consent was removed from the standard intake packet on 6/18/2025 and staff was informed through email that consents for probation and parole need to include a specific county, probation officer, and telephone number. The standards for completing consents will be subsequently reviewed with staff during all-staff meeting on 8/13/2025. Director will monitor through initial review of consents in all intake packets and Assistant Director and Office Manager will support with review of all newly completed consents prior to entering into the electronic health record to ensure compliance. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document the medical history, in accordance with the facility policy and procedure manual, in seven of seven client records reviewed.
The facility policy and procedure manual stated a medical history of the client is to be completed within 2 weeks of admission.
Client # 1 was admitted on March 13, 2025 and was still active at the time of the inspection. The medical history was due to be completed by March 27, 2025, but was not completed until April 17, 2025.
Client # 2 was admitted on February 28, 2025 and was still active at the time of the inspection. The medical history was due to be completed by March 14, 2025, but was not completed until June 5, 2025.
Client # 3 was admitted on April 25, 2025 and was still active at the time of the inspection. The medical history was due to be completed by May 9, 2025, but was not completed until May 15, 2025.
Client # 4 was admitted on October 2, 2024 and was discharged on November 13, 2024. The medical history was due to be completed by October 16, 2024, but was not completed until November 14, 2024.
Client # 5 was admitted on October 15, 2024 and was discharged on October 29, 2024. The medical history was due to be completed by October 29, 2024, but was not completed until November 2, 2024.
Client # 6 was admitted on April 16, 2025 and was discharged on May 28, 2025. The medical history was due to be completed by April 30, 2025, but was not completed until May 3, 2025.
Client # 7 was admitted on March 20, 2025 and was discharged on May 2, 2025. The medical history was due to be completed by April 3, 2025, but was not completed until April 8, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical documentation timelines were reviewed with clinical team on 6/20/2025 reinforcing the standard of submitting the biopsychosocial within 14 days. Director and Assistant director will monitor through weekly chart audits and documentation approval in the electronic health record. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document the drug and alcohol history, in accordance with the facility policy and procedure manual, in seven of seven client records reviewed.
The facility policy and procedure manual stated a drug and alcohol history of the client is to be completed within 2 weeks of admission.
Client # 1 was admitted on March 13, 2025 and was still active at the time of the inspection. The drug and alcohol history was due to be completed by March 27, 2025, but was not completed until April 17, 2025.
Client # 2 was admitted on February 28, 2025 and was still active at the time of the inspection. The drug and alcohol history was due to be completed by March 14, 2025, but was not completed until June 5, 2025.
Client # 3 was admitted on April 25, 2025 and was still active at the time of the inspection. The drug and alcohol history was due to be completed by May 9, 2025, but was not completed until May 15, 2025.
Client # 4 was admitted on October 2, 2024 and was discharged on November 13, 2024. The drug and alcohol history was due to be completed by October 16, 2024, but was not completed until November 14, 2024.
Client # 5 was admitted on October 15, 2024 and was discharged on October 29, 2024. The drug and alcohol history was due to be completed by October 29, 2024, but was not completed until November 2, 2024.
Client # 6 was admitted on April 16, 2025 and was discharged on May 28, 2025. The drug and alcohol history was due to be completed by April 30, 2025, but was not completed until May 3, 2025.
Client # 7 was admitted on March 20, 2025 and was discharged on May 2, 2025. The drug and alcohol history was due to be completed by April 3, 2025, but was not completed until April 8, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical documentation timelines were reviewed with clinical team on 6/20/2025 reinforcing the standard of submitting the drug and alcohol history, included within the biopsychosocial assessment, within 14 days. Director and Assistant director will monitor through weekly chart audits and documentation approval in the electronic health record. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document the personal history, in accordance with the facility policy and procedure manual, in all seven records reviewed.
The facility policy and procedure manual stated a personal history of the client is to be completed within 2 weeks of admission.
Client # 1 was admitted on March 13, 2025 and was still active at the time of the inspection. The personal history was due to be completed by March 27, 2025, but was not completed until April 17, 2025.
Client # 2 was admitted on February 28, 2025 and was still active at the time of the inspection. The personal history was due to be completed by March 14, 2025, but was not completed until June 5, 2025.
Client # 3 was admitted on April 25, 2025 and was still active at the time of the inspection. The personal history was due to be completed by May 9, 2025, but was not completed until May 15, 2025.
Client # 4 was admitted on October 2, 2024 and was discharged on November 13, 2024. The personal history was due to be completed by October 16, 2024, but was not completed until November 14, 2024.
Client # 5 was admitted on October 15, 2024 and was discharged on October 29, 2024. The personal history was due to be completed by October 29, 2024, but was not completed until November 2, 2024.
Client # 6 was admitted on April 16, 2025 and was discharged on May 28, 2025. The personal history was due to be completed by April 30, 2025, but was not completed until May 3, 2025.
Client # 7 was admitted on March 20, 2025 and was discharged on May 2, 2025. The personal history was due to be completed by April 3, 2025, but was not completed until April 8, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical documentation timelines were reviewed with clinical team on 6/20/2025 reinforcing the standard of submitting the personal history, included within the biopsychosocial assessment, within 14 days. Director and Assistant director will monitor through weekly chart audits and documentation approval in the electronic health record. |
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 client records, the facility failed to document the psychosocial evaluation, in accordance with the facility policy and procedure manual, in seven of seven client records reviewed.
The facility policy and procedure manual stated a psychosocial evaluation of the client is to be completed within 2 weeks of admission.
Client # 1 was admitted on March 13, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by March 27, 2025, but was not completed until April 16, 2025.
Client # 2 was admitted on February 28, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by March 14, 2025, but was not completed until June 5, 2025.
Client # 3 was admitted on April 25, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by May 9, 2025, but was not completed until May 15, 2025.
Client # 4 was admitted on October 2, 2024 and was discharged on November 13, 2024. The psychosocial evaluation was due to be completed by October 16, 2024, but was not completed until December 9, 2024.
Client # 5 was admitted on October 15, 2024 and was discharged on October 29, 2024. The psychosocial evaluation was due to be completed by October 29, 2024, but was not completed until November 2, 2024.
Client # 6 was admitted on April 16, 2025 and was discharged on May 28, 2025. The psychosocial evaluation was due to be completed by April 30, 2025, but was not completed until May 6, 2025.
Client # 7 was admitted on March 20, 2025 and was discharged on May 2, 2025. The psychosocial evaluation was due to be completed by April 3, 2025, but was not completed until April 7, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
clinical documentation timelines were reviewed with clinical team on 6/20/2025 reinforcing the standard of submitting the biopsychosocial within 14 days. Director and Assistant director will monitor through weekly chart audits and documentation approval in the electronic health record. |