INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 21, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, NASR Counsultant 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 personnel records and staff scheduling, the facility failed to ensure 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 projects hours of operations. A review of personnel records revealed that there was no documentation that Staff #1 had completed CPR training. A review of the facility ' s staffing schedule from September 29-October 26, 2025, indicated that Staff #1 worked the following dates/shifts by herself:2nd shift2nd shift2nd shift2nd shift2nd shift2nd shift2nd shift2nd shift2nd shift2nd shift2nd shift2nd shiftThis finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #1 has been trained and certified in CPR and First Aid as of 10/28/2025. The House Coordinator Supervisor will ensure that, going forward, all staff have their CPR and First Aid certifications before being placed on the work schedule. |
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 the facility failed to 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.DDAP staff observed that the sunroom door at the corner of the building does not lock. This is due to a damaged exterior door frame. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The damaged door frame was repaired and the locking mechanism restored by a contractor on 10/22/2025. The door is now fixed and working correctly.
Monitoring Plan:
- Monthly physical plant inspections conducted by the Director of Programs to ensure compliance with physical plant standards.
- The Director of Programs will provide ongoing staff reminders to report any observed hazards immediately.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the October 9, 2025, fire drill log during the inspection, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problem encountered and whether the fire alarm or smoke detector was operative. It was observed by DDAP staff that the October 9, 2025, fire drill log did not document whether the fire alarm or smoke detector was operative. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Conducted a training session on 11/03/2025 for all staff responsible for fire drills, covering documentation standards and emergency procedures.
Assigned the House Coordinator Supervisor to review and sign off on all fire drill logs before submission to ensure completeness.
Monitoring Plan:
- Fire drill logs will be audited monthly by the Director of Programs for completeness and accuracy.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on client interviews and a review of fire drill logs October 11, 2024, through October 9, 2025, the facility failed to set off the fire alarm or smoke detector during each fire drill. Clients reported that facility staff would not always set off the fire alarm but would verbally inform clients of fire drill.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Conducted mandatory training for all staff on proper fire drill procedures, including alarm activation, on 11/3/2025. All future fire drills shall be conducted by setting off the fire alarm.
Fire drill logs will be reviewed monthly by the Director of Programs to confirm alarm activation. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of medication administration records, the facility failed to provide medication as prescribed by a physician in two out of two applicable records reviewed. DDAP staff observed the following in the client records:Client #1 was admitted October 3, 2025, and was still active at the time of the inspection. This client was prescribed 10mg of Buspirone two times a day, once in the morning and once in the evening, On October 4, October 5, October 11 and October 12, the medication records only documents that the client received the evening dose of this medication. There was no further documentation in the client record.Client #2 was admitted August 26, 2025, and was still active at the time of the inspection. This client was prescribed 150 mg of Oxcarbazepine two times a day, once in the morning and once in the evening, On October 4, October 5, October 6, October 9, October 11 and October 12, the medication records only documents that the client received the evening dose of this medication. There was no further documentation in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director conducted a mandatory refresher training on medication administration and documentation standards for all House Coordinators on 11/03/2025.
Implemented a daily review of MARs to ensure all doses are documented and discrepancies are addressed. The review will be completed after the medication count during the shift change between the 2nd- and 3rd-shift House Coordinators. The outcome will be logged in the daily logbook by the 3rd Shift House Coordinator. Any discrepancies will be reported to the Director of Programs.
Staff who fail to document medication administration will receive progressive disciplinary action per HR policy.
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709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection the facility failed to ensure the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.It was observed by DDAP staff that the medication room was left unlocked during a time when no medication was being administered.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The medication room lock was inspected and verified to be fully functional. Effective immediately, all staff were instructed to ensure the medication room remains locked at all times when not in active use. The staff member responsible for leaving the room unsecured was formally addressed, and corrective action was implemented on October 30, 2025, in accordance with agency policy.
Monitoring Plan:
- The House Coordinator who is on duty will conduct daily spot checks of the medication room to ensure compliance.
- The Director of Programs will reinforce secure medication storage protocols during ongoing staff meetings and supervision sessions.
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