INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #3 was hired as a counselor on June 5, 2025, and was still in the position as of the date of the inspection. The training was completed on June 23, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action
Immediate:
Employee #3 has completed fire extinguisher training (June 23, 2025). Documentation is now on file.
Systemic:
1. Fire extinguisher training will be conducted on or by the first day of employment.
2. The employee checklist has been revised to include "Fire Extinguisher and Safety Training" as a mandatory item.
3. The Director of Programs will not clear clinical staff for active duty until this item is signed off.
4. The Head House Coordinator Supervisor will not clear technical staff for active duty until this item is signed off.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training to perform assigned tasks during emergencies.
Employee #3 was hired as a counselor on June 5, 2025, and was still in the position as of the date of the inspection. The training was completed on June 23, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action
Immediate:
Employee #3 has completed the emergency procedures training (June 23, 2025). Documentation is now on file.
Systemic:
1. Emergency procedures training will be conducted on or by the first day of employment.
2. The employee checklist has been revised to include "Fire Extinguisher and Safety Training" as a mandatory item.
3. The Director of Programs will not clear clinical staff for active duty until this item is signed off.
4. The Head House Coordinator Supervisor will not clear technical staff for active duty until this item is signed off. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of December 2024 - October 2025 fire drill logs, the facility failed to conduct a sleeping drill during the timeframe reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action
Immediate: A sleeping hour drill will be scheduled and conducted by January 15, 2026. Documentation will be filed in the fire drill log.
Systemic:
1. Fire drill schedule revised to include two sleeping hour drills per calendar year (every 6 months).
2. The night shift House Coordinator assigned responsibility for conducting and documenting sleeping hour drills.
3. Residents will be informed before the drill to minimize distress and ensure cooperation.
Monitoring:
Head House Coordinator Supervisor ? ensures drills are scheduled and logged.
Night shift House Coordinator ? conducts and documents sleeping hour drills.
Director of Residential Programs ? reviews log quarterly.
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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 document the administration of medication in five out of five applicable records.
Client #7 was admitted on May 19, 2025 and was still active at the time of the inspection. Metformin was prescribed twice a day. No documentation of medication being given on November 17, 2025 in the morning. In addition, the MARs was reviewed on November 18, 2025 at approximately 3:00 pm. The November 18, 2025 8:00 pm dose of Metformin was documented as having already been given.
Client #8 was admitted on August 19, 2025 and was still active at the time of the inspection. Aspirin was prescribed one time a day. No documentation of medication being given on November 7 and 13, 2025. Sentralre was prescribed one time per day. No documentation of medication being given on November 7, 9, 10, 11, 12, 13, 14, 15 and 16, 2025. Lisinopril was prescribed one time per day. No documentation of medication being given on November 12 and 13, 2025.
Client #9 was admitted on September 30, 2025 and was still active at the time of the inspection. Melatonin was prescribed once a day. No documentation of medication being given on November 8, 9, 12, 13, 14, 15, 16 and 17, 2025.
Client #10 was admitted on November 4, 2025 and was still active at the time of the inspection. Hydrochorathina was prescribed once a day. No documentation of medication being given on November 12, 2025. Fluticasone was prescribed once a day. No documentation of medication being given on November 7, 2025. Mirtazapine was prescribed once a day. No documentation of medication being given on November 9, 2025.
Client #11 was admitted on October 1, 2025 and was still active at the time of the inspection. Nalain was prescribed once a day. No documentation of medication being given on November 7 and 13, 2025. Topuramate was prescribed once a day. No documentation of medication being given on November 7 and 8, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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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.
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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 upon the review of medication administration records (MAR), the facility failed document drugs, which includes the name of the drug, the dosage, the staff person, the time, and the date in two out of five applicable records reviewed.
Client #7 was admitted on May 19, 2025 and was still active at the time of the inspection. A doctor ordered Metformin twice daily; however, the MAR showed to be given once daily at bedtime.
Client #9 was admitted on September 30, 2025 and was still active at the time of the inspection. A doctor ordered Quetiapine Fumarate 25 mg twice a day, and two orders for 50 mg twice a day; however, the MAR showed 50 mg given PRN and 300 mg, two tablets at bedtime. The 300 mg dose was listed twice on the MAR.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action
Immediate:
Physician orders for Client #7 and Client #9 have been reviewed and corrected in the MAR.
Systemic:
1. Transition to eMARS: Facility will implement an electronic MAR system by February 2, 2026.
2. eMARS will auto populate physician orders directly into the record, reducing transcription errors.
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.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 on a review of client records, the facility failed to document a individual treatment plan within the guidelines established in the facility's policy and procedures manual in six out of seven records reviewed. The facility's policy and procedures state the treatment plan must be completed within 14 days of admission.
Client #1 was admitted on March 26, 2025 and discharged on August 6, 2025. A comprehensive treatment plan was due on April 9, 2025; however, it was completed on April 16, 2025.
Client #2 was admitted on March 7, 2025 and discharged on September 29, 2025. A comprehensive treatment plan was due on March 21, 2025; however, it was completed on April 14, 2025.
Client #3 was admitted on July 2, 2025 and discharged on August 19, 2025. A comprehensive treatment plan was due on July 16, 2025; however, it was completed on July 17, 2025.
Client #5 was admitted on June 6, 2025 and discharged on August 6, 2025. A comprehensive treatment plan was due on July 20, 2025; however, it was completed on June 29, 2025.
Client #6 was admitted on April 10, 2025 and discharged on June 30, 2025. A comprehensive treatment plan was due on April 24, 2025; however, it was completed on May 9, 2025.
Client #7 was admitted on May 19, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due on June 2, 2025; however, it was completed on June 17, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Corrective Action
Immediate:
All identified treatment plans have been completed and filed.
Staff retrained on the updated policy requirements.
Systemic:
Facility policy has been revised:
1. A Preliminary Treatment Plan is completed within seven (7) days of admission.
2. A Comprehensive Treatment Plan is completed within thirty (30) days of the Preliminary Plan.
3. The electronic tracking system (integrated with the client record platform) will generate alerts.
4. The Quality Assurance Specialist will review timeliness during weekly audits.
Monitoring:
Director of Residential Programs ? ensures treatment plans are completed according to updated policy.
Quality Assurance Specialist ? monitors compliance through weekly audits and electronic alerts.
Assigned Counselor ? responsible for drafting and finalizing plans with the client.
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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 four out of seven records reviewed.
Client #1 was admitted on March 26, 2025 and discharged on August 6, 2025. A treatment plan update was completed on May 14, 2025, and the next update was due no later than June 14, 2025; however, the update was completed on July 17, 2025.
Client #2 was admitted on March 7, 2025 and discharged on September 29, 2025. A treatment plan was completed on April 14, 2025, and an update was due no later than May 14, 2025; however, the update was completed on May 16, 2025. Additionally, an update was completed on August 7, 2025 and the next update was due no later than September 7, 2025; however, it was completed on September 10, 2025.
Client #6 was admitted on April 10, 2025 and discharged on June 30, 2025. A treatment plan was completed on May 9, 2025, and an update was due no later than June 9, 2025; however, the update was completed on June 18, 2025.
Client #7 was admitted on May 19, 2025 and was still active at the time of the inspection. A treatment plan update was completed on July 16, 2025, and the next update was due no later than August 16, 2025; however, the update was completed on August 18, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 16, 2025, June 20, 2024, and December 18, 2023 licensing inspection.
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Plan of Correction
Corrective Action
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 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 four out of seven records reviewed.
Client #1 was admitted on March 26, 2025 and discharged on August 6, 2025. The treatment plan dated April 16, 2025, indicated group sessions twice a week and individual sessions weekly. There was no documented individual session the week of June 8-14, 2025. The week of June 8-14, 2025, only one group session was documented on June 10, 2025.
Client #2 was admitted on March 7, 2025 and discharged on September 29, 2025. A treatment plan dated April 14, 2025, indicated group sessions twice a week and individual sessions weekly. During the weeks of June 1-7 and June 15-21, 2025, only one group session was documented on June 1 and June 15, 2025.
Client #4 was admitted on May 29, 2025 and discharged on September 2, 2025. A treatment plan dated June 11, 2025, indicated group sessions twice a week and individual sessions weekly. During the week of July 27 - August 2, 2025, only one group session was documented on July 27, 2025.
Client #7 was admitted on May 19, 2025 and was still active at the time of the inspection. A treatment plan dated June 17, 2025, indicated group sessions twice a week and individual sessions weekly. There was no documented individual session the weeks of September 28 - October 11, 2025. Additionally, during the weeks of September 7 - 13, and September 21-27, 2025, only one group session was documented on September 8 and September 22, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 16, 2025, June 20, 2024, and December 18, 2023, licensing inspections.
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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)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations within the timeframe stated in the facility's policy and procedures manual in five out of seven records reviewed. The manual states case consultations shall occur monthly.
Client #1 was admitted on March 26, 2025 and discharged August 6, 2025. One case consultation occurred on April 28, 2025.
Client #2 was admitted on March 7, 2025 and discharged on September 29, 2025. One case consultation occurred on April 29, 2025.
Client #4 was admitted on May 29, 2025 and discharged on September 2, 2025. One case consultation occurred on June 25, 2025.
Client #6 was admitted on April 10, 2025 and discharged on June 30, 2025. One case consultation occurred on June 4, 2025.
Client #7 was admitted on May 19, 2025 and was still active at the time of the inspection. One case consultation occurred on July 3, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 16, 2025 licensing inspection.
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Plan of Correction
Policy Revision:
Effective December 22, 2025, facility policy now requires:
"A case consultation should be completed within ninety (90) days of admission for each resident."
Immediate Steps:
Policy manual updated and posted in the House Coordinator's office.
Systemic Preventive Measures:
1. Electronic Tracking:
Automatic reminders will be set for 75 days post admission to schedule a consultation before the 90 day deadline.
2. Compliance Checklist:
Quality Assurance Specialist will conduct weekly random chart audits to confirm "Case Consultation within 90 days" for each active resident.
Counselors will sign off to document compliance.
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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 treatment plan updates were submitted and approved by the Department for the January 16, 2025, June 20, 2024, and December 18, 2023 licensing inspections. Treatment plan updates was again found to be a deficiency in the November 18, 2025 licensing inspection.
A plan of correction for clients receiving counseling services according to their individual treatment plan were submitted and approved by the Department for the January 16, 2025, June 20, 2024, and December 18, 2023 licensing inspections. counseling services was again found to be a deficiency in the November 18, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Root Cause:
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 non compliance to leadership.
Corrective Action
Immediate:
Staff will be trained and retrained on updating treatment plans and counseling services, in accordance with the treatment plan requirements.
Systemic:
Electronic Systems: Transition to electronic tracking for treatment plan deadlines, counseling service provision, and MAR documentation by February 2, 2026. These systems reduce reliance on individual staff memory and ensure compliance even during turnover.
Onboarding Protocol: New clinical staff will receive compliance training on the use of electronic systems before their first day of work.
Compliance Oversight Committee: The establishment of an oversight committee by February 5, 2026, to review corrective action implementation monthly and escalate issues.
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