INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25-26, 2012 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:
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Plan of Correction
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705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a Physical plant inspection, the facility failed to maintain a minimum of two exits on every floor, that are separated by a minimum distance of 15 feet.The findings include:A physical plant inspection was conducted on July 25, 2012 between approximately 2:00 PM and 2:40 PM. The facility was required to maintain at least two exits on every floor. The facility's basement has only one exit. At the time of inspection, the basement was being used to store cans of paint and a few other miscellaneous items. Because the basement was unlocked and being used to store these items, the facility is required to ensure that the basement is in compliance with Chapter 705, Physical Plan Standards.An interview with the facility director was conducted on July 25, 2012 at approximately 2:40 PM. The facility director reported that the basement was supposed to be locked, but it was unlocked at the time of inspection.
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Plan of Correction
Program Director will retrain staff on keeping basement door locked at all times to ensure nothing is stored in basement at any time.
Signs will be posted to remind staff of need to keep basement door locked at all times.
Checking basement door is locked will be added to list of morning chores for designated staff to ensure that basement door is locked at all times.
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709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on a review of the facility's administrative documents, the facility failed to renew their letters of agreement/understanding with their primary referral sources at least every two years. The findings include:The facility's letters of agreement were reviewed on July 25, 2012. The facility's letters of agreement/understanding with their primary referral sources had not been updated in over two years. An interview with the facility director on July 25, 2012 confirmed the findings.
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Plan of Correction
All Referral Letters will be updated and placed in the Policy and Procedure by September 30, 2012.
Facility Director, or designated staff member, will create a tracking form for all Referral letters, which will be reviewed monthly to ensure that all future Referrals remain current.
The process for renewing Referral Letters will begin 60 days prior to future expiration dates to allow ample time to obtain all necessary signatures from all referral sources and ensure that Referrals are current. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document physical examinations that included an investigation of organ systems, an examination of the client's general appearance, and the physician ' s overall impression of the client. The findings include:Five client records requiring physical examinations were reviewed on July 26, 2012, specifically records # 1, 2, 3, 4 and 5. The facility did not document a physical examination to include an investigation of organ systems, an examination of the client's general appearance, and the physician's overall impression of the client in records # 1, 2 and 5.Client # 1 was admitted on 12/28/11. The physical examination in client # 1's record was not signed or dated by the physician, and it did not include an investigation of organ systems, an examination of the client's general appearance, and the physician's overall impression of the client.Client # 2 was admitted on 1/26/12. The physical examination in client # 2's record dated 1/31/12 did not include an investigation of organ systems, an examination of the client's general appearance, and the physician's overall impression of the client.Client # 5 was admitted on 5/9/12. The physical examination in client # 5's record did not have a dated signature, and it did not include an investigation of organ systems, an examination of the client's general appearance, and the physician's overall impression of the client.An interview with the facility director on July 26, 2012 confirmed the findings.
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Plan of Correction
Program Director, or designated staff member, will update current Initial Medical Examination Form to include the following; an investigation of organ systems, an examination of the client's general appearance, and the physician's overall impression of the client.
Facility Director, or designated staf, will ensure that all staff will be trained on the use of the updated Medical Examination Form.
Following the completion of each Initial Medical Examination, the Facility Director, or designated staff, will review completed Medical Examination Forms to ensure that the current form was used.
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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 the review of client records, the facility failed to document treatment plans that included type and frequency of treatment and rehabilitation services.The findings include:On July 26, 2012, treatment plans in five client records were reviewed for documentation type and frequency of treatment and rehabilitation services, specifically in records # 1, 2, 3, 4 and 5. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 2, 3, 4 and 5.Client # 1 was admitted on 12/28/11. The treatment plan in client # 1's record dated 1/17/12 did not include type and frequency of treatment and rehabilitation services.Client # 2 was admitted on 1/26/12. The treatment plan in client # 2's record dated 2/15/12 did not include type and frequency of treatment and rehabilitation services.Client # 3 was admitted on 2/15/12. The treatment plan in client # 3's record dated 3/4/12 did not include type and frequency of treatment and rehabilitation services.Client # 4 was admitted on 4/16/12. The treatment plan in client # 4's record dated 4/29/12 did not include type and frequency of treatment and rehabilitation services.Client # 5 was admitted on 5/9/12. The treatment plan in client # 5's record dated 5/30/12 did not include type and frequency of treatment and rehabilitation services.An interview with the facility director on July 26, 2012 confirmed the findings.
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Plan of Correction
Program Director will update current treatment plan templates, to include an identified area for "Type and Frequency of Treatment and Rehabilitation Services."
Facility Director will train all clinical staff on how to document updated treatment plan template.
Facility Director, or designated staff will review all treatment plans monthly to ensure "Type and Frequency of Treatment and Rehabilitation Services," is adequately documented on all treatment plans.
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