INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 18-19, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Nasr Consultant Group, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 employee files and the staff schedule, the facility failed to have at least one person trained in first aid with a CPR certification onsite during the project's hours of operation.
Employee # 1 was hired on October 30, 2024, as a House Coordinator. There is no CPR certification, or first aid training documented in this file. Employee # 1 was the only staff working overnight on February 18, 2025.
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Plan of Correction
The clinical supervisor will ensure that at least one staff member is trained in first aid with a CPR certification onsite during the project's hours of operation.
This will be done by reviewing all personnel charts to determine if first aid training with CPR certification training was completed. The clinical supervisor will document this training in the employee file if completed. The clinical supervisor will include the training in the employee's training plan if not completed.
The Program Director will be responsible for oversight. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on February 18, 2025, the facility failed to maintain hot water temperatures at or below 120 F.
Water temperature readings were 163 in both sinks of bathroom #2, and the computer room bathroom had readings of 154 for the hot water at the sink and 144 in the shower.
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Plan of Correction
The water temperature dial on the furnace was turned down. The project director purchased a water thermometer to check water temperatures. The thermometer is scheduled to arrive at the facility on 2/28/2025.
The Project Director will create and implement a temperature log and train all staff to check the water temperature. |
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 employee files, the facility failed to instruct all employees in the use of the fire extinguishers upon employment and document this instruction occurred.
Employee # 1 was hired on October 30, 2024, as a House Coordinator. There was no documentation of fire extinguisher training in this employee file.
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Plan of Correction
The facility director will instruct staff to use the fire extinguisher upon employment no later than seven (7) days from the date of employment. The facility director will document this instruction in the employee training attendance record.
In addition, the facility director will review all new hires' personnel charts to ensure they receive fire extinguisher training within the appropriate timeframes.
The facility director will train Employee #1 to use the fire extinguishers during the safety training no later than March 15, 2025, which will be documented in Employee #1's file. |
709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
Based on the review of employee files and the Orientation Policy in the Employee Handbook, the facility failed to document the orientation of new employees.
Per the Orientation Policy, an induction plan for each new employee, including an orientation checklist is to be completed. A written individual schedule of training is to be prepared and completed prior to the end of the employee ' s probation period of 90 days.
Employee # 1 was hired on October 30, 2024, as a House Coordinator. There was no documentation of an orientation checklist or written individual schedule of training.
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Plan of Correction
The facility director will document orientation, create a written individual training schedule for Employee #1, and file it in the employee's file.
In addition, the facility director will review all new hires' personnel charts to ensure they complete orientation, including a written individual training schedule within the appropriate timeframes. |
709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
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Observations
Based on a review of employee files, the facility failed to maintain personnel records that include an application or resume for employment.
Employee # 4 was hired on May 25, 2023, as a House Coordinator. There was no job application or resume documented in this staff file.
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Plan of Correction
The facility director will file Employee #4's resume in the employee's file.
In addition, the facility director will review all new hires and personnel charts to ensure that each chart includes an application and/or resume. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of employee files, the facility failed to maintain personnel records that include a written job description.
Employee # 4 was hired on May 25, 2023, as a House Coordinator. There was no written job description documented in this staff file.
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Plan of Correction
The facility director will file Employee #4's job description in the employee's file.
In addition, the facility director will review all new hires and personnel charts to ensure that each chart includes a job description. |
709.54(a)(6) LICENSURE Special dietary needs
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(6) Special dietary needs.
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Observations
Based on a review of client records and the Project Management Services policy, the facility failed to follow their written policy on special dietary needs.
Per the Project Management Services policy, individuals with special dietary needs will be provided with alternative meals by their special dietary needs.
Client # 1 was admitted on 6/24/24 and was still active at the time of the investigation. A food allergy was documented in this client record; however, there was no documentation of this allergy on the Food Allergies list posted in the kitchen.
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Plan of Correction
Client #1's allergy is now on the food allergies list posted in the kitchen.
Each counselor will be responsible for listing the clients' allergies on their respective caseloads on the food allergies list posted in the kitchen. In addition, the facility director will monitor client allergies during biweekly chart audits. |