INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2010 through June 10, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on July 7, 2010..
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to make document the facility's annual audit by the end of the facility's fiscal year which was June 30, 2009.The findings include:The policy and procedure manual was reviewed on June 7, 2010. The annual audit was not made available until June 6, 2010. The documentation was required to be made available prior to the end of their 2009 fiscal year which ended June 30, 2009.
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Plan of Correction
Central Office Personnel will ensure that The Annual Audit will be made available prior to the end of the Fiscal year ending June 30th of that year. If for some unforeseen circumstances the audit will not be made available by that date a request for an extension will be submitted. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on the physical plant tour, the facility failed to ensure that refrigerator unit only stored client medication. The findings include:The physical plant tour took place on June 10, 2010 at around 9:30 AM. During the tour, food was stored in the refrigerator unit which also stored the client medication.
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Plan of Correction
Staff will remove food currently stored in freezer section of the refrigeration unit currently designated for medication storage. No additional food will be stored in the refrigeration or freezer sections of that unit or any other unit while it is designated for medication storage.
Staff will conduct periodic checks to ensure that only medication is stored in the designated medication storage unit. |