INITIAL COMMENTS
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This report is a result of an on-site physical plant inspection follow up conducted on November 15, 2024, 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 on November 15, 2024, the facility failed to remain safe and in good repair at all times for the safety and well-being of residents, employees and visitors.
The bathroom located off the computer room was observed to have window with a broken lock.
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Plan of Correction
1. Program Director notified maintenance department on 11/19/24 to repair and replace broken lock in Bathroom C in the Computer Room.
2. Broken Lock will be repaired by 11/20/2024.
3. Program Director will train all staff on Facility Inspection and documentation of maintenance issues that need to be addressed. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on August 22, 2024, the facility failed to provide a fire-retardant mattress in good repair.
Bedroom B-6 was observed to have a mattress containing cracks and tears in the vinyl-like material.
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Plan of Correction
1. Program Director will dispose cracked mattress in Bedroom B-6 and replace with new mattress.
2. Program Director will conduct monthly checks on all facility bedding and mattresses.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on August 22, 2024, the facility failed to ventilate the bathroom by exhaust fan or window.
The bathroom located off the computer room was observed to have no exhaust fan and the window was unable to be opened due to being screwed shut.
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Plan of Correction
Program Director notified maintenance department to remove screw on August 24, 2024. Screw was removed by maintenance department on August 25, 2024. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted on August 22, 2024, the facility failed to store all food items off the floor.
A case of water was observed to be stored on the floor in the staff lounge.
A watermelon was observed to be stored on the floor in the kitchen.
A box or oranges, a bag of onions, and two cases of water were observed to be stored on the floor in the computer room.
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Plan of Correction
1. Program Director will purchase pallets to maintain appropriate storge.
2. Program Director will train all staff on proper storage for all food items.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual, along with staff interviews, the facility failed to follow its Transportation of Residents policy.
The Transportation of Residents policy indicates that whenever a resident is being transported, the driver must ensure that the requirements of the PA Vehicle Code are met including the use of passenger seat restraints.
The facility van was observed to be missing a seat belt latch for the front passenger seat. It was missing a seat belt for the second-row passenger seat located behind the driver's seat. Furthermore, the facility transported more clients than the van had seatbelts for. It was reported that a client sat on a milk carton between the driver and front passenger seat and a client was transported in the back of the van behind the last row of seats.
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Plan of Correction
1. Program Director will train all Staff on Nasr Consultants Transportation of Residents Policy and the PA Vehicle Code to ensure that the requirements of the PA Vehicle Code are met including the use of passenger seat restraints.
2. Program Director will issue a Documented Corrective Action and or/Termination of any Staff who violates
NASR Residential Transportation Policy.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on an interview with the Facility Director, the facility failed to file a written unusual incident report with the Department within the regulatory 3 business days.
It was reported that there was the presence of police at the facility on August 21, 2024. The facility did not submit a written report of this incident to the Department.
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Plan of Correction
1. Program Director will file written report for August 21, 2024 on DDAP Event Portal.
2. Program Director will file a written unusual incident report with DDAP within 3 business days.
3. Program Director will call DDAP Licensing Department when experiencing difficulty of sending information online or faxing. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in one of six records reviewed.
Client # 2 was admitted on 3/18/24 and was still active at the time of the complaint investigation. A treatment plan was completed on April 2, 2024, and the next update was due no later than May 2, 2024;
however, the next treatment plan update was dated May 20, 2024. The next update was then due no later than June 20, 2024; however, the next treatment plan update was dated 7/22/24.
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Plan of Correction
1. Program Director will conduct Clinical Documentation Training with Clinical Staff to ensure that all rehabilitation treatment plans are updated and signed
by client and staff every 30 days.
2. Program Director will conduct weekly chart reviews with Quality Assurance, Clinical Chart Auditor.
3. Program Director will review and discuss documented chart deficiencies to be corrected in weekly Clinical Staff Meetings.
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709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, along with staff and client interviews, the facility failed to verify that work done by the client at the project is an integral part of their treatment and rehabilitation plan.
Clients are completing chores at the facility that are not documented in the client records. These chores are outside of the work therapy goal on the clients treatment plans.
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Plan of Correction
1. Program Director will conduct training on Work Therapy with all Staff to ensure that Staff is not assigning chores to residents that do not coincide with client treatment plan.
2. Program Director will monitor all clients Work Therapy Assigned Chores. |