INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 3, 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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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician.
Client # 1 was admitted on April 21, 2025, and discharged on June 30, 2025. The client was prescribed a medication, and the prescription stated that the medication was to be taken three times per day. The medication administration records showed that the medication was not given as prescribed on 5/19/25, 5/20/25, and 6/1/25 through 6/10/2025.
Client # 4 was admitted on March 14, 2025, and discharged on May 19, 2025. The client was prescribed a medication, and the prescription stated that the medication was to be taken three times per day. The medication administration records showed that the medication was not given as prescribed on 5/10/25 through 5/19/25. Additionally, client # 4 was prescribed a medication and the prescription stated that the medication was to be taken twice per day. The medication administration records showed that this medication was not given as prescribed on 5/4/25 through 5/19/25.
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Plan of Correction
Corrective Actions:
1. Staff Training:
By August 4, 2025, the Director of Residential Programs will conduct mandatory refresher training for all House Coordinators responsible for administering medication. The training will emphasize accurate MAR documentation and strict adherence to physician orders.
2. Weekly Compliance Spot Checks:
The House Coordinator Supervisor will perform random weekly audits of MARs to identify inconsistencies, omissions, or deviations. Following each review, the House Coordinator will submit a completed Weekly Medication Administration Compliance Checklist to the Director of Residential Programs for oversight and follow-up.
3. Accountability Measures:
The Director of Programs will monitor MAR audit findings and enforce progressive discipline for staff found to have deviated from medication administration protocols.
These corrective actions are designed to ensure consistent and compliant practices, preventing the recurrence of documentation or protocol-related issues. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to provide a complete client record which shall include medication records.
Client # 1 was admitted on 4/21/25, and discharged on 6/30/25. Documentation of April 2025 medication records could not be found at the time of the investigation.
Client # 2 was admitted on January 29, 2025, and discharged on March 4, 2025. Documentation of medication records could not be found at the time of the investigation.
Client # 3 was admitted on February 27 2025, and discharged on June 19, 2025. Documentation of medication records could not be found at the time of the investigation.
Client # 4 was admitted on March 14, 2025, and discharged on May 19, 2025. Documentation of March 2025 and April 2025 medication records could not be found at the time of the investigation.
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Plan of Correction
Corrective Actions:
1. Transition to Electronic Medication Administration Record (eMAR):
The facility has initiated the implementation of an electronic MAR system, aimed at reducing documentation errors and enhancing medication tracking accuracy. This transition will facilitate timely record entries, supervisory review, and secure archiving. The rollout began on September 1, 2025, with comprehensive staff training scheduled for completion by August 18, 2025, to ensure seamless adoption and compliance.
2. Interim Documentation Safeguards:
To maintain documentation integrity until the eMAR system is fully operational, the facility has instituted the following protocol:
- Medication records are kept in the medication room in the MAR book throughout the client's stay.
- Upon discharge, all medical documentation?including MARs?is transferred to a secure, locked filing system within the Director's office.
- These interim measures ensure accessibility, confidentiality, and regulatory compliance during the transitional period, with full implementation targeted by August 4, 2025.
Oversight Responsibilities:
- The Executive Director will oversee the eMAR implementation process, including timeline adherence and system integration.
- The Director of Programs will monitor the interim documentation protocols to ensure consistent application and quality control.
These corrective measures are designed to eliminate gaps in recordkeeping and reinforce standardized, compliant medication administration practices throughout the facility.
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