INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 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, Inc. 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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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to have a way to ensure frozen food was at or below 0F.The deep freezer in the kitchen did not have a way to ensure frozen food was kept at or below 0F.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Corrective Action:
A freezer thermometer was purchased and installed in the deep freezer. Staff verified the freezer temperature upon installation and documented the reading. The thermometer is positioned in the warmest area of the freezer to ensure accurate monitoring.
Systemic Corrective Action:
A Daily Freezer Temperature Log has been added to the kitchen's routine.
1. A House Coordinator will record the freezer temperature once per shift, ensuring continuous compliance.
2. Any reading above 0°F triggers:
- Immediate adjustment of the freezer
- Re‑check within 30 minutes
- Notification to the House Coordinator Supervisor if the temperature does not return to the appropriate range.
3. Responsible Persons:
- Program Director: Oversight of compliance, monthly audit review.
- House Coordinator Supervisor: Ensures daily logs are completed and responds to out‑of‑range readings.
- House Coordinators: Daily temperature checks and documentation
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers in the facility were inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher located in the common room did not have an inspection date documented on the tag. This finding was reviewed with the facility during the licensing inspection.
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Plan of Correction
Immediate Corrective Action:
- The fire extinguisher in the common room was removed and replaced with a unit that has a current inspection tag showing the annual inspection date.
- All other extinguishers in the facility were checked the same day to ensure inspection tags were present, legible, and current.
Systemic Corrective Action:
The facility has established a standing annual service contract with a certified fire extinguisher inspection company to ensure all extinguishers are inspected on an annual fixed schedule.
The vendor will provide:
- Annual inspection
- Tag updates
- Replacement recommendations
- Written service reports for compliance files
Responsible Persons:
1. Program Director: Oversight of annual inspections and compliance documentation
2. Fire Safety Vendor: Annual inspection, tagging, and service reports
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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 the review of client records, the facility failed to follow their policy to contact a client's emergency contact within twelve hours of leaving against medical advice in one out of two applicable records reviewed.Client #4 was admitted to the facility on June 18, 2025, and left against medical advice on August 28, 2025. There was no documentation that the emergency contact was notified.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Corrective Action:
- The facility reviewed the incident involving Client #4 and confirmed that the emergency contact was not notified within the required timeframe.
- Staff involved received immediate corrective coaching on:
- The AMA notification requirement
- Documentation expectations
- Where and how to record the contact attempt
- The AMA section of the client record was updated to reflect the corrective review.
Systemic Corrective Action:
1. The facility has updated its AMA protocol to include:
A mandatory AMA Notification Form that must be completed at the time of discharge or within 12 hours.
Required documentation fields:
- Date/time of AMA departure
- Emergency contact name and number
- Date/time of contact attempt
- Outcome (successful contact, voicemail left, no answer, etc.)
- Staff signature
The form must be uploaded into the EHR system (Opus) by the assigned counselor.
2. Weekly Chart Audits
The weekly chart audit tool has been updated to include:
- Verification that AMA notifications were completed and documented
- Confirmation that the 12-hour requirement was met.
3. All clinical and residential staff received a brief in service training during a staff meeting covering:
- AMA procedures
- Emergency contact notification requirements
- Documentation standards
- Training attendance was documented and placed in personnel files.
Responsible Persons:
- Program Director: Oversight of AMA procedures, review of weekly audits
- Quality Assurance Specialist: Completes weekly chart audits to ensure AMA notifications are completed and documented within 12 hours
- House Coordinator on-duty: Initiates the AMA notification process and completes the required form, then places the form in the appropriate Counselor's box to upload to the EHR system (Opus).
- Counselor: The assigned Counselor uploads the AMA Notification Form to the EHR system (Opus).
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in five out of seven records reviewed.Client #1 was admitted on September 11, 2025 and was still active at the time of the inspection. The informed and voluntary consent form for the funding source was signed by the client on December 5, 2025; however, the facility confirmed that billing started approximately one week after admission. Client #3 was admitted on October 20, 2025 and was still active at the time of the inspection. The informed and voluntary consent form for the funding source was signed by the client on November 12, 2025; however, the facility confirmed that billing started approximately one week after admission. Client #4 was admitted on June 18, 2025 and discharged on August 28, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #5 was admitted on September 3, 2025 and was discharged on November 10, 2025. The informed and voluntary consent form for the funding source was signed by the client on October 22, 2025; however, the facility confirmed that billing started approximately one week after admission. Client #7 was admitted on May 20, 2025 and was discharged on October 29, 2025. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Corrective Action:
Staff responsible for intake received immediate corrective coaching on: Ensuring consents are completed at admission, not weeks later.
Systemic:
1. The Program Coordinator is responsible for the completion of timely consents for the funding source during the admission process.
2. The Quality Assurance Specialist will conduct random weekly audits of clients' charts using a quality assurance checklist to ensure the completion of timely consents for the funding source during the initial intake process.
3. The Director of Residential Programs is responsible for oversight of confidentiality compliance.
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in two out of seven records reviewed.Client #2 was admitted on August 18, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a pharmacy signed by the client on August 28, 2025, that had identified the purpose for disclosure as emergency contact and medical. The facility acknowledged that emergency contact was not the intended purpose of the consent. Client #7 was admitted on May 20, 2025 and discharged on October 29, 2025. The record contained one informed and voluntary consent to release information to a pharmacy signed by the client on May 30, 2025, that had identified the purpose for disclosure as emergency contact and medical. The facility acknowledged that emergency contact was not the intended purpose of the consent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Corrective Action:
- The consents for Clients #2 and #7 were reviewed, and the facility confirmed that "emergency contact" was selected in error.
- For Client #2 (active case), a corrected consent was completed with the client, specifying the accurate purpose of disclosure.
- For Client #7 (discharged), the facility documented the error in the closed chart and noted that the issue was identified during the licensing review.
- Staff responsible for completing consents received immediate coaching on:
1. Selecting the correct purpose of disclosure
2. Avoiding multi‑purpose selections unless clinically appropriate
3. Reviewing the form with the client before signing
Systemic:
1. The Program Coordinator is responsible for the completion of consents to release information during the admission process, which includes clarifying the intended purpose of the consent.
2. The assigned Counselor is responsible for the completion of consents to release information after the admission process, which includes clarifying the intended purpose of the consent.
3. The Quality Assurance Specialist will conduct random weekly audits of clients' charts using a quality assurance checklist to ensure the completion of consents to release information that clarifies the intended purpose of the consent.
3. The Director of Residential Programs is responsible for oversight of confidentiality compliance.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection and a review of the facility's files, the facility failed to inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State, and local laws and regulations. The facility did not have documentation that the inspections were conducted. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Immediate Corrective Action:
The Director of Residential Programs conducted a complete inspection of all medication storage areas, including the dispensing station, using the inspection form.
Systemic:
1. The Director of Residential Programs is now responsible for completing the quarterly inspections. They will also send the completed inspection form to the Executive Director for review and sign-off.
2. The Executive Director will review and sign off on each inspection within 48 hours.
3. The Executive Director will send the signed form back to the Director of Residential Programs for filing.
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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 in three out of seven client records. Client #4 was admitted on June 18, 2025 and discharged on August 28, 2025. The client was prescribed a medication once in the morning. The medication administration records showed that the medication was not given on July 1 and 2, 2025. The client was prescribed another medication to be administered in the evening. The medication administration records showed that the medication was not given on July 4, 5, and July 9 through July 31, 2025. The client was prescribed another medication to be administered in the morning. The medication administration records showed that the medication was not given from August 1 through 28, 2025. There was no additional documentation included indicating a reason why the medications were not given as prescribed. Client #6 was admitted on March 25, 2025 and was discharged on October 18, 2025. The client was prescribed a medication to be administered at 12 noon. The medication administration records showed that the medication was not given on April 17, 18, 19, 21, May 2, 4, 5, 7, 15, 16, 17, 24, 25, 29 and 30, 2025. There was no additional documentation included indicating a reason why the medications were not given as prescribed. Client #7 was admitted on May 20, 2025 and discharged on October 29, 2025. The client was prescribed a medication to be administered in the morning and at 4 P.M. The medication administration records showed that the medication was not administered the morning of September 19, 2025, and at 4 P.M. on July 29 and 30, 2025. There was no additional documentation included indicating a reason why the medications were not given as prescribed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
1. Transition to eMARS: Facility will implement an electronic medication administration record (eMAR) system by February 2, 2026.
2. All authorized staff who are responsible for accurate documentation and adherence to eMARS protocols will be trained on the new system.
3. Built-in alerts will flag missed doses, duplicate entries, or discrepancies.
4. Audit trails will capture staff initials, time, and date automatically.
5. Until eMARS is fully operational, a daily MAR review by the night shift House Coordinator will provide a 2-step verification process.
6. Monthly audits by the Director of Residential Programs will verify accuracy and compliance.
Monitoring:
The Director of Residential Programs oversees eMARS implementation, verifies accuracy, and conducts monthly audits.
All authorized staff are responsible for accurate documentation and adherence to eMARS protocols.
Staff who fail to document medication administration appropriately will receive progressive disciplinary action per HR policy. |
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 document treatment plan updates within the regulatory timeframe in six out of seven records reviewed.Client #2 was admitted on August 18, 2025 and was still active at the time of the inspection. A treatment plan was completed on November 7, 2025, and the next update was due no later than December 7, 2025; however, the update was completed on December 12, 2025.Client #3 was admitted on October 20, 2025 and was still active at the time of the inspection. A treatment plan was completed on November 7, 2025, and an update was due no later than December 7, 2025; however, there was no documentation that one was completed. Client #4 was admitted on June 18, 2025 and discharged on August 28, 2025. A treatment plan was completed on July 3, 2025, and an update was due no later than August 2, 2025; however, the update was completed on August 15, 2025.Client #5 was admitted on September 3, 2025 and was discharged on November 10, 2025. A treatment plan was completed on September 19, 2025, and the next update was due no later than October 19, 2025; however, the update was completed on October 21, 2025.Client #6 was admitted on March 25, 2025 and discharged on October 18, 2025. A treatment plan was completed on May 7, 2025, and the next update was due no later than June 6, 2025; however, the update was completed on June 11, 2025.Client #7 was admitted on May 20, 2025 and discharged on October 29, 2025. A treatment plan was completed on May 30, 2025, and the next update was due no later than June 29, 2025; however, the update was completed on July 3, 2025. The next update was due no later than August 2, 2025; however, the next update was completed on August 15, 2025. The next update was due no later than September 14, 2025; however, the update was completed on September 26, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate:
All identified treatment plan updates have been completed and filed.
Systemic:
1. Implementation of an Electronic Treatment Plan Tracking System (integrated with client record platform).
2. Clinical staff trained on setting up the treatment plan tracking system.
3. Automatic alerts are generated at 25 days to remind counselors.
4. The Quality Assurance Specialist will review timeliness during weekly audits.
Monitoring:
Director of Residential Programs ? ensures clinical staff are trained in setting up the treatment plan tracking system.
Quality Assurance Specialist ? monitors compliance through weekly audits and electronic alerts.
Assigned Counselor ? responsible for drafting and finalizing treatment plan updates with the client. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in six out of seven records reviewed.Client #2 was admitted on August 18, 2025 and was still active at the time of the inspection. The treatment plans dated November 7, and December 12, 2025, indicated two group sessions and one individual session a week. There was only one group session documented the weeks of November 9 and 16, 2025. Client #3 was admitted on October 20, 2025 and was still active at the time of the inspection. The treatment plan dated November 7, 2025, indicated two groups and one individual session a week. During the week of November 16, 2025, there was only one group documented. Client #4 was admitted on June 18, 2025 and discharged on August 28, 2025. The treatment plans dated July 3, and August 15, 2025, indicated two groups and one individual session a week. During the weeks of July 13, 27, August 3 and August 10, 2025, there was only one group counseling session documented. Client #5 was admitted on September 3, 2025 and discharged on November 10, 2025. The treatment plan dated September 19, 2025, indicated two groups and one individual session a week. There was only one group session documented the week of September 21, 2025. Client #6 was admitted on March 25, 2025 and discharged on October 18, 2025. The treatment plans dated May 7, June 11, July 3, July 28, August 29 and September 26, 2025, indicated two groups and one individual session a week. There were no groups counseling sessions documented in the weeks of June 1, and July 13, 27, and August 24, 2025. There was only one group documented the weeks of June 8, 15, 22, July 20, August 3, 10, 31, September 7, 14, 21, 28, and October 5 and 12, 2025. There was no individual session documented for the weeks of May 25, June 22, August 3, 10, 31, and September 28, 2025. This is a repeat citation from November 25, 2024 licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
1. The Assigned Counselor is responsible for delivering and documenting all therapeutic sessions.
2. The Quality Assurance Specialist will conduct random weekly audits of clients' charts using a quality assurance checklist to ensure treatment is being provided according to the treatment plan.
3. The Executive Director will review the quality assurance checklist during bi-weekly chart reviews with each clinical staff member. |
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, the facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in seven out of seven records reviewed.Client #1 was admitted on September 11, 2025 and was still active at the time of the inspection. There was no documentation that work done by the client at the project was an integral part of their treatment on the October 3, 2025 treatment and rehabilitation plan.Client #2 was admitted on August 18, 2025 and was still active at the time of the inspection. There was no documentation that work done by the client at the project was an integral part of their treatment on the September 12, 2025 treatment and rehabilitation plan.Client #3 was admitted on October 20, 2025 and was still active at the time of the inspection. There was no documentation that work done by the client at the project was an integral part of their treatment on the November 7, 2025 treatment and rehabilitation plan.Client #4 was admitted on June 18, 2025 and discharged on August 28, 2025. There was no documentation that work done by the client at the project was an integral part of their treatment on the July 3, 2025 treatment and rehabilitation plan.Client #5 was admitted on September 3, 2025 and was discharged on November 10, 2025. There was no documentation that work done by the client at the project was an integral part of their treatment on the September 19, 2025 treatment and rehabilitation plan.Client #6 was admitted on March 25, 2025 and discharged on October 18, 2025. There was no documentation that work done by the client at the project was an integral part of their treatment on the May 7, 2025 treatment and rehabilitation plan.Client #7 was admitted on May 20, 2025 and discharged on October 29, 2025. There was no documentation that work done by the client at the project was an integral part of their treatment on the May 30, 2025 treatment and rehabilitation plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Corrective Action:
Staff responsible for treatment planning received immediate corrective coaching during the clinical meeting on including client (chores) work as treatment and including it in each client's individualized treatment plan.
Systemic:
The treatment plan template has been revised to include a mandatory work as a treatment goal, requiring staff to document:
- Whether the client is assigned work activities
- The therapeutic purpose (e.g., structure, responsibility, vocational readiness, social skills, community living skills)
- Specific goals and measurable objectives
- Staff interventions
- Frequency and method of evaluation
This ensures the requirement cannot be overlooked.
Responsible Persons:
1. Director of Residential Programs: Oversight of treatment planning compliance and audit review
2. Quality Assurance Specialist: will conduct random weekly audits of clients' charts using a quality assurance checklist to ensure the documentation of treatment goals that include work as treatment.
3. Clinical Staff: Completion of individualized treatment plans, including work as treatment goals.
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