INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 2025 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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705.7 (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, which was conducted at approximately 1:00 pm, the refrigerator in the kitchen registered a temperature of 50 degrees Fahrenheit. The temperature of the refrigerator was takn a second time, at approximately 1:35 pm, and it registered at 52 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Refrigerator will remain locked between food service times to ensure that the refrigerator is closed and temperature is maintained. 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 five of seven applicable client records reviewed.
Client #1 was admitted on April 9, 2025 and was active at the time of inspection. A release of information form, signed and dated by the client on April 9, 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 #2 was admitted on March 25, 2025 and was active at the time of inspection. A release of information form, signed and dated by the client on March 25, 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 #3 was admitted on November 12, 2024 and was active at the time of inspection. A release of information form, signed and dated by the client on November 12, 2024, 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 #4 was admitted on February 6, 2025 and was discharged on May 27, 2025. A release of information form, signed and dated by the client on February 6, 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 #6 was admitted on February 24, 2025 and was discharged on March 28, 2025. A release of information form, signed and dated by the client on February 24, 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 6/17/2025 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. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident logs and client records, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that involved physical or sexual assault by staff or a client.
There was documentation of separate assault incidents, one involving two clients and the other involving a client to staff, occurring on October 1, 2024 and May 27, 2025. However, neither incident was reported to the Department at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will reeducate all staff about the categories for DDAP reportable incidents and the process for doing so by 7/31/2025. As part of this process, staff will be instructed to report any physical or sexual assault or other reportable incident to director immediately. This will be monitored by office manager and, when reported, Director will electronically submit an incident report to DDAP within 3 days detailing the incident per the requirement.
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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 five of six applicable 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 April 9, 2025 and was still active at the time of the inspection. The medical history was due to be completed by April 23, 2025, but was not completed until April 30, 2025.
Client # 2 was admitted on March 25, 2025 and was still active at the time of the inspection. The medical history was due to be completed by April 8, 2025, but was not completed until April 27, 2025.
Client # 4 was admitted on February 6, 2025 and was discharged on May 27, 2025. The medical history was due to be completed by February 20, 2025, but was not completed until March 16, 2025.
Client # 5 was admitted on June 7, 2024 and was discharged on August 15, 2024. The medical history was due to be completed by June 21, 2024, but was not completed until June 30, 2025.
Client # 6 was admitted on February 24, 2025 and was discharged on March 28, 2025. The medical history was due to be completed by March 10, 2025, but was not completed until April 2, 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 which includes the medical history. 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 five of six applicable 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 April 9, 2025 and was still active at the time of the inspection. The drug and alcohol history was due to be completed by April 23, 2025, but was not completed until April 30, 2025.
Client # 2 was admitted on March 25, 2025 and was still active at the time of the inspection. The drug and alcohol history was due to be completed by April 8, 2025, but was not completed until April 27, 2025.
Client # 4 was admitted on February 6, 2025 and was discharged on May 27, 2025. The drug and alcohol history was due to be completed by February 20, 2025, but was not completed until March 16, 2025.
Client # 5 was admitted on June 7, 2024 and was discharged on August 15, 2024. The drug and alcohol history was due to be completed by June 21, 2024, but was not completed until June 30, 2025.
Client # 6 was admitted on February 24, 2025 and was discharged on March 28, 2025. The drug and alcohol history was due to be completed by March 10, 2025, but was not completed until April 2, 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 five of six applicable 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 April 9, 2025 and was still active at the time of the inspection. The personal history was due to be completed by April 23, 2025, but was not completed until April 30, 2025.
Client # 2 was admitted on March 25, 2025 and was still active at the time of the inspection. The personal history was due to be completed by April 8, 2025, but was not completed until April 27, 2025.
Client # 4 was admitted on February 6, 2025 and was discharged on May 27, 2025. The personal history was due to be completed by February 20, 2025, but was not completed until March 16, 2025.
Client # 5 was admitted on June 7, 2024 and was discharged on August 15, 2024. The personal history was due to be completed by June 21, 2024, but was not completed until June 30, 2025.
Client # 6 was admitted on February 24, 2025 and was discharged on March 28, 2025. The personal history was due to be completed by March 10, 2025, but was not completed until April 2, 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 five of six applicable 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 April 9, 2025 and was still active at the time of the inspection. The biopsychosocial evaluation was due to be completed by April 23, 2025, but was not completed until May 6, 2025.
Client # 2 was admitted on March 25, 2025 and was still active at the time of the inspection. The biopsychosocial evaluation was due to be completed by April 8, 2025, but was not completed until April 28, 2025.
Client # 4 was admitted on February 6, 2025 and was discharged on May 27, 2025. The biopsychosocial evaluation was due to be completed by February 20, 2025, but was not completed until March 17, 2025.
Client # 5 was admitted on June 7, 2024 and was discharged on August 15, 2024. The biopsychosocial evaluation was due to be completed by June 21, 2024, but was not completed until June 30, 2025.
Client # 6 was admitted on February 24, 2025 and was discharged on March 28, 2025. The biopsychosocial evaluation was due to be completed by March 10, 2025, but was not completed until April 3, 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. |