INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, NASR Consultant Group, Incorporated 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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705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher, as there was no fire extinguishers present at the facility.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The fire extinguisher was temporarily removed by PMI Maintenance during scheduled painting and ADA accessibility modifications related to hallway lighting expansion and was not immediately reinstalled
Once identified, corrective action was taken promptly on 12/22/2025. Both required fire extinguishers in the front and back hallways were replaced and securely mounted on the wall, and the facility is currently fully compliant with fire safety requirements.
To prevent future occurrences, an internal protocol has been implemented requiring administrative sign-off following any maintenance work to ensure all safety equipment is present and operational. If this issue were to occur again, a fire extinguisher would be immediately mounted within the office.
We appreciate the opportunity to address this matter and remain committed to compliance and client safety. Additional information can be provided if needed. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records, the facility failed to inform the client that they may not be discriminated against based on creed in seven out of seven records reviewed.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 11/19/2025, Dr. Boswell, Executive Director, corrected the Client Rights and Responsibilities form by adding the missing term "Creed" in accordance with Policy §709.30. This update has been completed in both the electronic record-keeping system (Opus) and the Policy and Procedures Manual. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation which shall include project policies, hours of operation, fee schedule and services provided in seven out of seven records reviewed.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dr. Boswell, Executive Director, is currently in the process of correcting the Client Rights and Responsibilities form to include program policies, hours of operation, fee schedule, and services provided. These updates are scheduled to be completed and reflected in both the electronic record-keeping system (Opus) and the Policy and Procedures Manual by 01/07/2026. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 upon a review of client records, the facility failed to develop a treatment plan with the client according to the facility's policy and procedures manual in three out of seven records reviewed. The policy states the treatment plan must be completed within 30 days of admission.Client #1 was admitted on March 18, 2025 and discharged on June 18, 2025. A comprehensive treatment plan was due on April 17, 2025. It was completed on April 29, 2025.Client #3 was admitted on April 28, 2025 and discharged on July 24, 2025. A comprehensive treatment plan was due on May 28, 2025. It was completed on May 30, 2025.Client #4 was admitted on April 29, 2025 and discharged on July 29, 2025. A comprehensive treatment plan was due on May 29, 2025. It was completed on May 30, 2025.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 18, 2024, June 21, 2024, and December 19, 2023 licensing inspections.
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Plan of Correction
High turnover among clinical staff led to gaps in training, documentation, and continuity of care. Corrective actions were not consistently reinforced with new staff. Reliance on manual systems made compliance vulnerable to staffing changes. Supervisory oversight did not promptly escalate noncompliance to leadership.
Corrective Action Immediate:
Staff will be trained and retrained on comprehensive treatment plans and updates to those treatment plan requirements.
Systemic:
Electronic Systems: Transition to electronic tracking for treatment plan deadlines, February 6, 2026. These systems reduce reliance on individual staff memory and ensure compliance even during turnover.
Onboarding Protocol: New clinical staff will receive compliance training within their first week, including hands on use of electronic systems.
Compliance Oversight Committee: The establishment of an oversight committee by February 6, 2026, to review corrective action implementation monthly and escalate issues.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of five applicable records reviewed.Client #2 was admitted on May 6, 2025 and discharged on November 6, 2025. A comprehensive treatment plan was completed on May 28, 2025 with an update due no later than July 28, 2025; however, the update was completed on August 6, 2025. Client #6 was admitted on March 6, 2025 and discharged on June 30, 2025. A comprehensive treatment plan was completed on March 28, 2025 with an update due no later than May 28, 2025; however, it was completed on June 2, 2025.Client #7 was admitted on April 1, 2025 and discharged on October 1, 2025. A treatment plan update was completed on June 3, 2025 with the next update due no later than August 3, 2025; however, it was completed on August 13, 2025.The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 18, 2024, June 21, 2024, December 19, 2023, December 15, 2022, December 20, 2021, October 15, 2020, October 11, 2019, and January 8, 2019 licensing inspections.
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Plan of Correction
High turnover among clinical staff led to gaps in training, documentation, and continuity of care. Corrective actions were not consistently reinforced with new staff. Reliance on manual systems made compliance vulnerable to staffing changes. Supervisory oversight did not promptly escalate noncompliance to leadership.
Corrective Action Immediate:
Staff will be trained and retrained on comprehensive treatment plans and updates to those treatment plan requirements.
Systemic:
Electronic Systems: Transition to electronic tracking for treatment plan deadlines, February 6, 2026. These systems reduce reliance on individual staff memory and ensure compliance even during turnover.
Onboarding Protocol: New clinical staff will receive compliance training within their first week, including hands on use of electronic systems.
Compliance Oversight Committee: The establishment of an oversight committee by February 6, 2026, to review corrective action implementation monthly and escalate issues. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for developing a comprehensive treatment plan were submitted and approved by the Department for the December 18, 2024, June 21, 2024, and December 19, 2023 licensing inspection. Comprehensive treatment plans was again found to be a deficiency in the November 17, 2025 licensing inspection.A plan of correction for treatment plan updates were submitted and approved by the Department for the December 18, 2024, June 21, 2024, December 19, 2023, December 15, 2022, December 20, 2021, October 15, 2020, October 11, 2019 and January 8, 2019 licensing inspection. Comprehensive treatment plans was again found to be a deficiency in the November 17, 2025 licensing inspection.A plan of correction for providing counseling services according to the treatment plan were submitted and approved by the Department for the December 18, 2024, June 21, 2024, and December 19, 2023 licensing inspection. Counseling services according to the treatment plan was again found to be a deficiency in the November 17, 2025 licensing inspection.
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Plan of Correction
High turnover among clinical staff led to gaps in training, documentation, and continuity of care.
Corrective actions were not consistently reinforced with new staff.
Reliance on manual systems made compliance vulnerable to staffing changes.
Supervisory oversight did not promptly escalate noncompliance to leadership.
Corrective Action Immediate:
Staff will be trained and retrained on comprehensive treatment plans and updates to those treatment plan requirements.
Systemic: Electronic Systems: Transition to electronic tracking for treatment plan deadlines, February 6, 2026. These systems reduce reliance on individual staff memory and ensure compliance even during turnover.
Onboarding Protocol: New clinical staff will receive compliance training within their first week, including hands on use of electronic systems.
Compliance Oversight Committee: The establishment of an oversight committee by February 6, 2026, to review corrective action implementation monthly and escalate issues. |