INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2007 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 September 24, 2007.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to present the plan documenting qualifications and training of staff at the time of inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel and training records, the facility failed to document an assessment of staff training needs in five of seven employee records reviewed, #3, 4, 5, 6 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document individual training plans for employees in four of seven records reviewed, #3, 4, 5 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedule for August 1 through August 22, 2007 and CPR certifications, the facility failed to provide sufficient coverage of staff persons certified in CPR on the 2nd, 3rd and weekend shifts. Three employees did not have CPR certifications and were working alone on different shifts.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on the physical plant inspection, the facility failed to provide documentation that mattresses were fire retardant.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that exits were unobstructed. The exit from the second floor bedroom was obstructed with a table in front of the window and the second floor lounge area exit was obstructed by a chair in front of the walkway to the exit.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 and training records, the facility failed to document fire extinguisher training upon staff employment in three of seven records reviewed, #5, 6 and 7. Fire extinguisher training was not documented with the required time frame on two of seven records reviewed, #2 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 and training records, the facility failed to document emergency training in three of seven records reviewed, #5, 6 and 7. The facility failed to document this training within the required time frame in two of seven records reviewed, #2 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill documentation, the facility failed to document a fire drill during sleeping hours during the last six months. The last fire drill conducted during sleeping hours was on October 18, 2006.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
The facility failed to document performance evaluations in five of seven records reviewed, #3, 4, 5, 6 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
The facility failed to inform the individual, by a written copy of their evaluations in five of seven records reviewed, #3, 4, 5, 6 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
The facility failed to demonstrate that employees were informed of their employee rights in three of seven records reviewed, #4, 5 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
The facility failed to have written job descriptions in two of seven records reviewed, #6 and 7. Job descriptions for activities daily living counselors (ADL's) failed to accurately describe their duties for this position. Job descriptions stated that ADL's would provide therapy services to clients in two of seven records reviewed, #4 and 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to comply with the restriction imposed at 4 Pa. Code, Subsection 255.5 (b) by allowing "all other information" to be released to parole and probation officers, judges and case managers in one of four client records reviewed, #1. The facility failed to obtain an informed and voluntary consent from the client in four of four records reviewed, #1, 2, 3 and 4. Consent to release information forms were completed by other sources and did not include the components of a valid consent form. Information was sent without client consent.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the facility's policy and the inspection of the medication area, the facility failed to provide a secured locked container for client medications in need of refrigeration. Food was found in the refrigerator that stores client medication.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(4) 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:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of the medication administration record, the facility failed to document client medication administration for August 2007. The employee assigned to observe self-administration of client medications did not document that clients received their medication in the medication administration record.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 complete medical histories in three of four records reviewed. The client's symptoms and illnesses were missing in one of four records reviewed, #4. The facility failed to document a medical history in one of four records reviewed, #3. The clients's family medical history and symptoms and illnesses were not completed in one record, #2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 a complete drug and alcohol history in three of three records reviewed, #1, 3 and 4. The drug and alcohol history did not include the clients's lengths and patterns of use. Also, the client's perception of their use was not addressed in record #2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 a complete psychosocial evaluation in four of four records reviewed, #1, 2, 3 and 4. The psychosocial evaluation was historical rather than evaluative in two client records, #3 and 4 and not completed in two records, #1 and 2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 document treatment plans in two of four records reviewed, #1 and 2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short and long term goals for treatment in two of four records reviewed, #1 and 2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 services in two of four records reviewed, #1 and 2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document support services in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in two of two records reviewed, #3 and 4. The treatment plan update was not completed in client record #3 and was completed late in #4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document counseling services were provided according to the treatment plan in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling services on a regular and scheduled basis in four of four records reviewed, #1, 2, 3 and 4. Treatment plans stated that clients would be seen once a week for individual counseling sessions and this was not documented in the record of services or client progress notes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(e)(4) LICENSURE Economic support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
The facility failed to provide documentation of services for economic support.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
The facility failed to provide documentation of services for educational support.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(e)(6) LICENSURE Vocational Support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
The facility failed to provide documentation of services for vocational support.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document the client's record of services in four of four records reviewed, #1, 2, 3 and 4. There were several weeks where no documentation of service was recorded.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document the data and assessment portion of group progress notes and did not document the client's participation in group in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document individual goals with time frames in two of two client records reviewed, #3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure and client records, the facility failed to document follow up information as per policy in two of two client records reviewed, #3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(b) LICENSURE Standardized Forms
709.53. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of client records, the facility failed to develop and maintain client records on standardized project client record forms in four of four records reviewed, #1, 2, 3 and 4. Consent to release information forms were not standardized.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |