INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted May 13, 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on May 13, 2025, the facility failed to maintain the building in good repair at all times.
- The back hallway outside of the B Bathroom was observed to have a damaged, leaking ceiling with ceiling material falling down into a yellow bucket on the floor.
- The counselor office near the staff bathroom was observed to have a hole in the ceiling.
- Client bedroom B2 was observed to have a hole in the wall. Also, the window screen was taped together and hanging off the window.
- Client bedroom B4 was observed to have extremely filthy/stained carpet and a stained mattress cover.
- Client bedroom B5 was observed to have broken blinds on the window.
- Client bedroom B6 was observed to have a torn window screen.
- The basement was observed to have torn carpet near the steps in the room with the large glass windows
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Plan of Correction
The Executive Director and landlord hired a contractor to complete the following repairs. They are:
1. B-Wing Hallway: Damaged, leaking ceiling
2. Hole in the ceiling near the staff bathroom
Client Bedrooms:
3. B2: Hole in the wall and window screen
4. B4: Clean stained carpet and replace stained mattress cover
5. B5: Replace broken blinds on the window
6. B6: Replace torn window screen
7. The basement where the torn carpet was near the steps
All repairs are scheduled to be completed by June 16, 2025.
The House Coordinator Supervisor will monitor physical plant/building damages daily during shift. Once a needed repair is identified repairs will be completed no longer than two (2) weeks after being identified.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on May 13, 2025, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
- The staff bathroom was observed to have a cracked toilet tank lid.
- The second client bathroom towards the back of the building was observed to have a broken towel rack with a sharp metal piece protruding from the wall. Also, the light was not functioning.
- The bathroom where the cleaning supplies are stored was observed to have a hole in the ceiling tile.
- The bathroom in client bedroom B3 was observed to have broken floor tiles and peeling wallpaper.
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Plan of Correction
The Executive Director hired a contractor to complete the following repairs. They are:
Bathrooms:
1. Staff Bathroom: Replace cracked toilet tank lid
2. Second Client Bathroom (Back of Building): The light was fixed and operational.
3. Cleaning Supply Bathroom: Repair or place a hole in the ceiling tile.
4. The Bathroom in Client Bedroom B3: Replaced flooring, removed peeling wallpaper, and painted the walls.
Note: The metal identified the second client bathroom towards the back of the building is not from a broken towel rack, but from a former urinal pipe valve that was closed.
All repairs are scheduled to be completed by June 16, 2025.
The House Coordinator Supervisor will monitor physical plant/building damages daily during shift. Once a needed repair is identified repairs will be completed no longer than two (2) weeks after being identified.
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