INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection on May 21 and 29, 2026, 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. The client bathroom off of the kitchen did not have either paper towels or a mechanical dryer.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
House Coordinators are required to complete hourly rounds. During the rounds, bathrooms will be checked to ensure all necessary items are in place, including paper towels.
House Coordinators are required to document the hourly rounds on the Hourly Rounds Log. The completed form requires signatures from the on-duty staff. The House Coordinator Supervisor will also sign the form after reviewing it.
This plan of correction will be fully implemented no later than July 30, 2026. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the January - May 2026 fire drill logs, the facility failed to document whether the fire alarm or smoke detector was operative during the February 21, 2026 fire drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all-staff meeting was held on June 13, 2026, to address problem areas within the program. This included documentation of fire drills.
The House Coordinator Supervisor reminded all staff that the fire drill log form must be completed in full after a fire drill.
The House Coordinator Supervisor will conduct monthly audits of all fire drill logs to ensure all required fields, including alarm/smoke detector operability, are documented.
This plan of correction will be fully implemented no later than July 30, 2026. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in two out of seven applicable client records reviewed. There was no release of information forms for the funding source and pharmacy. Staff confirmed billing had occurred and medications had been delivered from the pharmacy.
Client #1 was admitted on December 10, 2025, and was still active at the time of the inspection.
Client #2 was admitted on December 8, 2025, and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There are now completed release of information forms for Client #1 and Client #2 for both the funding source and pharmacy.
During the weekly clinical meetings, the Weekly Clinical Meeting Review form must be completed for every client on each counselor's caseload. This form verifies if all the necessary Release of Information forms are complete.
The Director of Residential Programs will verify this information during the weekly clinical meetings by reviewing the electronic health record. ُThe completed form requires signatures from the assigned Counselor and the Director of Residential Programs. Lastly, the copies of the completed forms will be sent to the Executive Director upon completion of the weekly clinical meetings.
This plan of correction will be fully implemented no later than July 30, 2026. |
709.32 (c) 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:
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Observations
Based on a review of administrative documents and client records, the facility failed to implement their written policy and procedures regarding all medications used by clients. The facility's procedures were developed for paper medication administration records and documenting client medication through those identified means. The facility upgraded to an electronic medication administration record and failed to have procedures to record medication administration and missing medication.
In addition, the facility failed to follow guidelines outlined in the client handbook regarding filling of medications. The handbook states "All medications and scripts must be brought back to the facility and filled by Nasr staff." Clients were overheard on the telephone refilling their medication prescriptions. Current clients were interviewed and revealed they are responsible for calling to refill medications and not the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have revised our medication control policy to include a provision for adopting an electronic medication administration record (eMAR). Our revised policy outlines procedures for recording medication administration and medication omissions.
Additionally, we have hired a certified Psychiatric Mental Health Nurse Practitioner (PMHNP) who prescribes any necessary medication and fills them through our newly adopted eMAR system.
Our revised medication control policy establishes a three‑tier oversight system designed to prevent medication errors, ensure accurate documentation, maintain regulatory compliance, and promote resident safety. They are:
-LEVEL 1 ? SHIFT‑TO‑SHIFT MEDICATION COUNT & eMAR RECONCILIATION
-LEVEL 2 ? WEEKLY MEDICATION RECONCILIATION & SUPERVISORY REVIEW
-LEVEL 3 ? BI‑WEEKLY MEDICATION CONTROL SUMMARY REPORT
Level 1 is monitored by the House Coordinator Supervisor. Level 2 is monitored by the Director of Residential Programs. Level 3 is monitored by the Executive Director.
This plan of correction will be implemented no later than July 30, 2026.
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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 observation of medication pass and review of client records, the facility failed to follow their policy and procedures manual regarding administration of medications.
The policy and procedures manual states "The House Coordinator will work with the resident to ensure the removal of the appropriate dosage of medication" and "The House Coordinator will observe the resident while she swallows the medication." During medication administration on May 21, 2026, the facility failed to follow both of these procedures.
The policy and procedures manual states "Staff will note appropriately, i.e., refusal of medication, out of the program, and medication errors". Staff confirmed no medications are given to clients to be taken with them when out of the program and the doses are missed. No documentation of missed doses of medications was provided during the inspection.
There was not any documentation in the client records indicating reasons for missed medication doses.
Client #1 was admitted on December 10, 2025, and was still active at the time of the inspection. A review of client #1 ' s medication administration log identified the following medications were not administered/missed:
Sertraline HCI 50 mg oral tablet was prescribed to the client to be taken one time a day, but during the period of April 26 - May 21, 2026, the medication was missed nine times.
Quetiapine fumarate 100 mg oral tablet was prescribed to the client to be taken one time a day, but during the period of April 26 - May 21, 2026, the medication was missed twenty-four times.
Client #2 was admitted on December 8, 2025, and was still active at the time of the inspection. A review of client #2 ' s medication administration log identified the following medications were not administered/missed:
Magnesium Oxide 400 mg oral tablet was prescribed to the client to be taken one time a day, but during the period of April 26 - May 21, 2026, the medication was missed fifteen times.
Gabapentin 100 mg oral capsule was prescribed to the client to be taken three times a day, but during the period of April 26 - May 21, 2026, the medication was missed eighteen times.
Pantoprazole sodium 40 mg delayed release oral tablet was prescribed to the client to be taken one time a day, but during the period of April 26 - May 21, 2026, the medication was missed thirteen times.
Buspirone HCI 30 mg oral tablet was prescribed to the client to be taken one time a day, but during the period of April 26 - May 21, 2026, the medication was missed four times.
Folic acid 1 mg oral tablet was prescribed to the client to be taken one time a day, but during the period of April 26 - May 21, 2026, the medication was missed one time.
Propranolol HCI 10 mg oral tablet was prescribed to the client to be taken one time a day PRN, but during the period of April 26 - May 21, 2026, the medication was missed five times.
Client #3 was admitted on February 2, 2026, and was still active at the time of the inspection. A review of client #3 ' s medication administration log identified the following medications were not administered/missed:
Hydroxyzine pamoate 25 mg oral capsule was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed seven times.
Mirtazapine 15 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed six times.
Buprenorphine HCI 8 mg sublingual film was prescribed to the client to be taken twice day, but during the period of April 26 - May 21, 2026, the medication was missed seven times.
Buspirone HCI 5 mg oral tablet was prescribed to the client to be taken one time a day, but during the period of April 26 - May 21, 2026, the medication was missed five times.
Client #4 was admitted on April 1, 2026, and was still active at the time of the inspection. A review of client #4 ' s medication administration log identified the following medications were not administered/missed:
Atorvastatin calcium 40 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed fourteen times.
Fluoxetine 40 mg oral capsule was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed nine times.
Prazosin HCI 1 mg oral capsule was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed seven times.
Clonidine HCI 0.1 mg patches was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed eight times.
Mirtazapine 7.5 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed seven times.
Pantoprazole sodium 40 mg delayed release oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed two times.
Metoprolol succinate 25 mg 24hr extended release oral tablet was prescribed to the client to be take 1/2 of a tablet once a day, but during the period of April 26 - May 21, 2026, the medication was missed two times.
Aspirin 81 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed three times.
Losartan potassium 25 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed one time.
Methadone 100 mg take home bottles were prescribed to be taken on Saturday and Sundays during the clinic's closure. Methadone medication was not listed on the electronic MARs and paper documentation was being used. There was no documentation of the client receiving their medication from April 1 - 26, May 2, May 16, May 17, and May 29, 2026.
Client #5 was admitted on April 15, 2026 and was still active at the time of the inspection. A review of client #5 ' s medication administration log identified the following medications were not administered/missed:
Quetiapine fumarate 50 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed nine times.
Docusate calcium 100 mg oral capsule was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed nine times.
Oxcarbazepine 600 mg oral tablet was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed twenty-one times.
Omeprazole 40 mg delayed release oral capsule was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed nine times.
Buprenorphine HCI 8 mg tablet was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed eight times.
Sertraline HCI 100 mg oral tablet was prescribed to the client for 1/2 tablet to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed six times.
Client #6 was admitted on April 1, 2026, and was still active at the time of the inspection. A review of client #6 ' s medication administration log identified the following medications were not administered/missed:
Naproxen 500 mg oral tablet was prescribed to the client for one tablet to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed twenty-three times.
Montelukast sodium 10 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed eleven times. The MARs indicated 28 tablets were to be dosed.
Mucinex Expectorant 600 mg 12 hr extended release oral tablet was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed seven times.
Fluticare 50 mcg/ actuat metered dose nasal spray was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed eight times.
Loratadine 10 mg 24hr oral tablet was prescribed to the client to be taken twice a day, but during the period of April 26 - May 21, 2026, the medication was missed sixteen times.
Client #7 was admitted on April 7, 2026, and was still active at the time of the inspection. A review of client #7 ' s medication administration log identified the following medications were not administered/missed:
Clonidine HCI 0.1 mg oral tablet was prescribed to the client to be taken one to two times a day, but during the period of April 26 - May 21, 2026, the medication was missed six times.
Buprenorphine HCI 12 mg sublingual film was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed two times.
Mirtazapine 15 mg oral tablet was prescribed to the client to be taken once a day, but during the period of April 26 - May 21, 2026, the medication was missed seven times.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 18, 2025, annual licensing inspection.
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Plan of Correction
We have revised our medication control policy to include a provision to document the reasons for missed medication doses in client records. All direct care staff will be required to attend a mandatory training regarding our revised medication control policy.
The training will include how to document the reason for missed medication doses in the electronic medication administration record (eMAR). Staff will be assessed in the training environment on their ability to document the reason for missed medication doses.
The House Coordinator Supervisor will monitor the documentation of missed medication doses. Staff who fail to document the reason for missed medication doses will be held accountable in accordance with the Personnel Manual.
This plan of correction will be implemented no later than July 30, 202 |
709.32 (c) (2) 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:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on observation, the facility failed to securely store controlled substances according to the facility's policy and procedures manual. The policy and procedures manual states "The House Coordinator will ensure that the interior medication box is locked, as well as the medication cart itself when done with medication times." Department staff observed three client lock boxes containing narcotic medications unlocked.
Client #3 was admitted on February 2, 2026, and was still active at the time of the inspection. The unlocked medication box contained Buprenorphine.
Client #4 was admitted on April 1, 2026, and was still active at the time of the inspection. The unlocked medication box contained Methadone.
Client #5 was admitted on April 15, 2026, and was still active at the time of the inspection. The unlocked medication box contained Buprenorphine.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have revised our medication control policy to include the provision for securely storing controlled substances. The medication control policy now reads, "All medications are stored under a double lock, which includes a locked room and a locked medicine cabinet."
The double-locked system will be monitored by all direct care staff (House Coordinators) during their daily shift hourly rounds. The House Coordinator Supervisor will address any violations of the double-lock system in accordance with the Personnel Manual.
This plan of correction will be fully implemented no later than July 30, 2026. |
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 review of the facility's policy manual and medication storage area, the facility failed to follow their policy for medication control related to inspection of storage areas. The policy states "The medication storage area is inspected quarterly by a program director." There was no documentation of quarterly inspections by the program director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have revised our medication control policy to include the provision for securely storing controlled substances. The medication control policy now reads, "The medication storage area is inspected quarterly by the Program Director."
The Program Director will inspect the medication storage area using the Qua Medication Storage & Control Audit Checklist. The completed forms will be filed in the medication storage area. Furthermore, the Program Director will send a copy of the completed form to the Executive Director.
The Executive Director will monitor the inspection of the medication storage area.
This plan of correction will be fully implemented no later than July 30, 2026. |
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 medication administration records (MARs), the facility failed to record drugs as prescribed by the physician, which includes the name of the drug, and the dosage in six out of seven applicable records reviewed.
Client #2 was admitted on December 8, 2025, and was still active at the time of the inspection. Gabapentin 100 mg oral capsule was prescribed to the client to be taken three times a day. On the MARs, the medication was listed to be given twice a day, both times were scheduled for 12:00 pm. The first list 12:00 pm entry indicated the amount to administer was 40 capsules and the second entry indicated the amount to administer was 90 capsules.
Ibuprofen 800 mg oral tablet was prescribed as a PRN medication. It was not listed as a PRN on MARs.
Pantoprazole sodium 40 mg delayed release oral tablet was prescribed to the client to be taken one time a day. The entry on the MARs indicated the amount to administer was 18 tablets. In addition, the medication is listed on the MARs to be given twice at 8:00 am and again at 8:00 pm.
Buspirone HCI 30 mg oral tablet was prescribed to the client to be taken one time a day. The MARs indicated the amount to administer was 15 mg tablet to be given twice daily at 8:00 am and 12:00 pm. The 8:00 am MARs entry indicated to dispense 53 tablets.
Folic acid 1 mg oral tablet was prescribed to the client to be taken one time a day. The MARs entry indicated the amount to administer was 175 tablets.
Propranolol HCI 10 mg oral tablet was prescribed to the client to be taken one time a day PRN. The MARs did not indicate the medication was PRN.
Potassium Cl 20 mg effervescent oral tablet was prescribed to be given once a daily. The MARs indicated the amount to administer was 25 mg to be given one time daily.
Cetirizine HCI 10 mg oral tablet was prescribed to be given once daily. The MARs indicated the amount to administer was 18 tablets.
Prenatal vitamin plus low was prescribed to be given one tablet daily. It was not listed on the MARs during the May 21, 2026, inspection.
Client #3 was admitted on February 2, 2026, and was still active at the time of the inspection.
Hydroxyzine pamoate 25 mg oral capsule was prescribed to the client to be taken twice a day. The MARs indicated the amount to administer was 42 tablets.
Buprenorphine HCI 8 mg sublingual film was prescribed to the client to be taken twice day. The MARs indicated the amount to administer was 56 films.
Buspirone HCI 5 mg oral tablet was prescribed to the client to be taken one time a day. The MARs indicated the amount to administer was 24 tablets.
Client #4 was admitted on April 1, 2026, and was still active at the time of the inspection.
Albuterol sulfate inhalation solution was prescribed 1-2 puff every 4-6 hours as needed. The medication prescription was filled on April 17, 2026. From April 26 - May 21, 2026, the MARs showed to give the medication three times a day without indicating it was a PRN. From May 22 - 29, 2026, the medication was no longer listed on the MARS. The medication was still located in the client's medication box. There was no documentation for the medication being discontinued by the physician.
Atorvastatin calcium 40 mg oral tablet was prescribed to the client to be taken once a day. The MARs indicated the amount to administer was 27 tablets.
Fluoxetine 40 mg oral capsule was prescribed to the client to be taken once a day. MARs indicated the amount to administer was 30 tablets.
Pantoprazole sodium 40 mg delayed release oral tablet was prescribed to the client to be taken once a day. The MARs indicated the amount to administer was 30 tablets.
Metoprolol succinate 25 mg 24hr extended release oral tablet was prescribed to the client to be take 1/2 of a tablet once a day. The MARs indicated the amount to administer was 15 tablets.
Aspirin 81 mg oral tablet was prescribed to the client to be taken once a day. The MARs indicated the amount to administer was 30 tablets.
Valsartan 160 mg oral tablet was prescribed to the client to be taken once a day. The MARs indicated the amount to administer was 30 tablets.
Losartan potassium 25 mg oral tablet was prescribed to the client to be taken once a day. The MARs indicated the amount to administer was 20 tablets.
Client #5 was admitted on April 15, 2026, and was still active at the time of the inspection.
Quetiapine fumarate 50 mg oral tablet was prescribed to the client to be taken once a day. The MARs indicated the amount to administer was 25 tablets.
Docusate calcium 100 mg oral capsule was prescribed to the client to be taken twice a day. The MARs indicated the amount to administer was 37 tablets.
Oxcarbazepine 600 mg oral tablet was prescribed to the client to be taken twice a day. The MARs indicated the amount to administer was 69 tablets.
Omeprazole 40 mg delayed release oral capsule was prescribed to the client to be taken twice a day. The MARs indicated the amount to administer was 33 capsules.
Buprenorphine HCI 8 mg tablet was prescribed to the client to be taken twice a day. The MARs indicated the amount to administer was 4 tablets.
Sertraline HCI 100 mg oral tablet was prescribed to the client for 1/2 tablet to be taken once a day. The MARs indicated the amount to administer was one tablet daily.
Mucus relief 600 mg tablet prescription was filled on April 30, 2026, to be given one tablet in morning and bedtime. The medication was in the client's medication box but not listed on the MARs.
Senna-Time 8.6 mg oral tablet PRN up to two times per day was listed on the MARs but medication was not in the client's medication box.
Client #6 was admitted on April 1, 2026, and was still active at the time of the inspection.
Hydroxyzine pamoate 25 mg oral capsule 24hr extended release was prescribed to the client for one tablet to be taken daily. The MARs stated for the medication to be given three times a day at 8:00 am, 4:00pm and 8:00pm.
Montelukast sodium 10 mg oral tablet was prescribed to the client to be taken once a day. The MARs indicated the amount to administer was 28 tablets.
Mucinex Expectorant 600 mg 12 hr extended release oral tablet was prescribed to the client to be taken twice a day. The MARs indicated the amount to administer was 10 tablets.
Loratadine 10 mg 24hr oral tablet was prescribed to the client to be taken twice a day. The MARs stated for the medication to be given twice a day at 8:00 am and 12:00 PM. The MARs indicated the amount to administer was 29 tablets.
Advair 1 puff twice a day prescription was filled on January 15, 2026. Medication was in the client's medication box but was not on the MARs.
Benzocaine-menthol oral lozenge prescription was filled on February 2, 2026. Medication was in the client's medication box but was not on the MARs.
Client #7 was admitted on April 7, 2026, and was still active at the time of the inspection.
Bupropion HCI 300 mg extended release oral tablet was prescribed to the client to be taken once a day. The MARs stated 150 mg table to be dispensed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 18, 2025, annual licensing inspection.
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Plan of Correction
We have revised our medication control policy to include a provision for recording drugs as prescribed in the electronic medication administration record (eMAR). This includes the medication name and dosage. All direct care staff will be required to attend a mandatory training regarding our revised medication control policy.
The training will include how to correctly record drugs as prescribed in our newly adopted eMAR system. Staff will be assessed in the training environment on their ability to record drugs as prescribed in our newly adopted eMAR system.
The House Coordinator Supervisor will monitor documentation to ensure that medication is recorded correctly as prescribed, including the medication name and dosage. Staff who fail to correctly record medications as prescribed will be held accountable in accordance with the Personnel Manual.
This plan of correction will be implemented no later than July 30, 2026. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of the facility's policy manual and medication storage area, the facility failed to follow their policy for medication control related to security of drugs, including, but not limited to, the loss, theft or misuse of drugs. The policy states "When the resident is discharged, the resident's medication is given to the resident or the person responsible for placement." As well as "Methods for control and accountability of drugs, include, but are not limited to: When a medication is discontinued or damaged, a House Coordinator or other staff is authorized to properly remove medication when witnessed by another House Coordinator or other staff. When a medication is removed, the staff must document disposal on the back of the medication log."
During the inspection of the medication storage area, medication for discharged clients was still present. They had not been provided to the client or their person responsible for placement at discharge. There were also loose pills that were dislodged from damaged medication packages. Upon discussion during the inspection, the House Coordinator did log and dispose of the medications.
The loose medications found in current client medication areas were in two out of seven applicable clients reviewed.
Client #2 was admitted on December 8, 2025, and was still active at the time of the inspection. Five loose pills from damaged medication packets were observed at the bottom of the individual ' s medication bin.
Client #6 was admitted on April 1, 2026, and was still active at the time of the inspection. One loose pill from damaged medication packets was observed at the bottom of the individual ' s medication bin.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have revised our medication control policy to include provisions for logging and disposing of medication when they are discontinued, changed, or damaged. The medication control policy now reads, "When a medication is discontinued, changed, or damaged, the House Coordinator Supervisor or the staff member designated by the House Coordinator Supervisor is authorized to properly remove medication from active storage. When the medication is removed, the House Coordinator Supervisor or the staff member designated by the House Coordinator Supervisor must remove the medication from the eMAR system. Additionally, the House Coordinator Supervisor must document the removal of medication on the Weekly Medication Reconciliation & Supervisory Review form." Furthermore, "When the resident is discharged, the resident's medication is given to the resident or the person responsible for placement."
All direct care staff will be required to attend a mandatory training regarding our revised medication control policy. The training will include how to log and dispose of discontinued, changed, or damaged medications. Staff will be assessed in the training environment on their ability to log and dispose of the medications.
The House Coordinator Supervisor will ensure that discontinued, changed, or damaged medication is logged and disposed of. Staff who fail to properly log and dispose of discontinued, changed, or damaged medications will be held accountable in accordance with the Personnel Manual.
This plan of correction will be implemented no later than July 30, 2026.
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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 three out of six applicable records reviewed.
Client #3 was admitted on February 2, 2026, and was still active at the time of the inspection. A treatment plan update was completed on March 5, 2026, and the next update was due no later than April 5, 2026; however, the next update was completed on April 6, 2026.
Client #9 was admitted on January 6, 2026, and was discharged on April 6, 2026. A treatment plan update was completed on February 11, 2026, and the next update was due no later than March 13, 2026; however, the next update was completed on March 16, 2026.
Client #13 was admitted on February 12, 2026, and was still active at the time of the inspection. A treatment plan update was completed on April 9, 2026, and the next update was due no later than May 9, 2026; however, the next update was completed on May 11, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 18, 2025, and January 16, 2025, annual licensing inspections.
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Plan of Correction
During the weekly clinical meetings, the Weekly Clinical Meeting Review form must be completed for every client on each counselor's caseload. This form verifies that all treatment plan updates are complete for each client within the regulatory timeframe.
The Director of Residential Programs will verify this information during the weekly clinical meetings by reviewing the electronic health record. The completed form requires signatures from the assigned Counselor and the Director of Residential Programs. Lastly, copies of the completed forms will be sent to the Executive Director after the weekly clinical meetings.
This plan of correction will be fully implemented no later than July 30, 2026. |
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 seven out of seven applicable records reviewed. There was no documentation of reasons for missed sessions in the clients' records.
Client #3 was admitted on February 2, 2026, and was still active at the time of the inspection. The treatment plan dated February 9, 2026, indicated group sessions twice weekly and individual sessions once a week. The weeks of February 22-28 and March 22-28, 2026, did not have any individual sessions. In addition, there was one group session on March 17, 2026, for the week of March 15-21, 2026, and on April 7, 2026, for the week of April 5 - 11, 2027.
Client #8 was admitted on January 8, 2026, and discharged on March 30, 2026. The treatment plan dated January 21, 2026, indicated group sessions twice weekly and individual sessions once a week. The weeks of February 1-7, February 22-28 and March 22-28, 2026, did not have any documented individual sessions. In addition, the week of March 15-28, 2026, the client did not receive any group therapy.
Client #9 was admitted on January 6, 2026, and discharged on April 6, 2026. The treatment plan dated January 15, 2026, indicated group sessions twice weekly and individual sessions once a week. The weeks of January 18-24, February 1-7, February 22-28, March 4-14 and March 22 through discharge date of April 6, 2026, did not have any documented individual sessions. In addition, there were no group sessions March 14, 2026, through discharge date of April 6, 2026.
Client #10 was admitted on March 30, 2026, and discharged on May 18, 2026. The treatment plan dated April 1, 2026, indicated group sessions twice weekly and individual sessions once a week. There were no documented individual sessions from May 3, 2026, through discharge date of May 18, 2026. In addition, there was one group session dated April 8, 2026, for the week of April 5-11, 2026.
Client #11 was admitted on January 20, 2026, and discharged on February 10, 2026. The treatment plan dated January 28, 2026, indicated group sessions twice weekly and individual sessions once a week. During the client's admission to the facility, there was one documented individual session on January 31, 2026.
Client #12 was admitted on March 4, 2026, and discharged on April 27, 2026. The treatment plan dated January 28, 2026, indicated group sessions twice weekly and individual sessions once a week. The week of March 22-28, 2026, there was no documented individual session. In addition, there was one group session dated March 17, 2026, for the week of March 15-21, 2026.
Client #13 was admitted on February 12, 2026, and was still active at the time of the inspection. The treatment plan dated March 12, 2026, indicated group sessions twice weekly and individual sessions once a week. The weeks of March 15-21, March 29-April 4 and April 26-May 2, 2026, did not have any documented individual sessions. In addition, there was one group session dated March 17, 2026, for the week of March 15-21, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 18, 2025, January 16, 2025, June 20, 2024 and December 18, 2023.
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Plan of Correction
During the weekly clinical meetings, the Weekly Clinical Meeting Review form must be completed for every client on each counselor's caseload. This form verifies that all individual and group progress notes are complete for each client. This includes documenting reasons for any missed sessions.
The Director of Residential Programs will verify this information during the weekly clinical meetings by reviewing the electronic health record. The completed form requires signatures from the assigned Counselor and the Director of Residential Programs. Lastly, copies of the completed forms will be sent to the Executive Director after the weekly clinical meetings.
This plan of correction will be fully implemented no later than July 30, 2026. |
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 a case consultation monthly, per facility policy, in four out of six applicable records reviewed.
Client #3 was admitted on February 2, 2026, and was still active at the time of the inspection. The only documented case consultation occurred on March 11, 2026.
Client #8 was admitted on January 8, 2026, and discharged on March 30, 2026. The only documented case consultation occurred on March 19, 2026.
Client #9 was admitted on January 6, 2026, and discharged on April 6, 2026. The only documented case consultation occurred on February 9, 2026.
Client #13 was admitted on February 12, 2026, and was still active at the time of the inspection. The only documented case consultation occurred on April 8, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 18, 2025, and January 16, 2025, annual licensing inspections.
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Plan of Correction
During the weekly clinical meetings, the Weekly Clinical Meeting Review form must be completed for every client on each counselor's caseload. This form verifies that all case consultations have been completed within the regulatory timeframe.
The Director of Residential Programs will verify this information during the weekly clinical meetings by reviewing the electronic health record. The completed form requires signatures from the assigned Counselor and the Director of Residential Programs. Lastly, copies of the completed forms will be sent to the Executive Director after the weekly clinical meetings.
This plan of correction will be fully implemented no later than July 30, 2026. |
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 was submitted and approved by the Department for the November 18, 2025, and January 16, 2025, annual licensing inspections. Treatment plan updates were again found to be a deficiency in the May 21 - 29, 2026, licensing inspection.
A plan of correction for providing services according to the client's individual treatment plans was submitted and approved by the Department for the November 18, 2025, January 16, 2025, June 20, 2024, and December 18, 2023, annual licensing inspections. Following treatment plans were again found to be a deficiency in the May 21 - 29, 2026 licensing inspection.
A plan of correction for case consultations was submitted and approved by the Department for the November 18, 2025, and January 16, 2025, annual licensing inspections. Case consultations were again found to be a deficiency in the May 21 - 29, 2026 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have modified our plan of corrections for treatment plan updates, providing services according to the client's individual treatment plan, and case consultations.
During the weekly clinical meetings, the Weekly Clinical Meeting Review form must be completed for every client on each counselor's caseload. This form verifies that all treatment plan updates and case consultations have been completed within the regulatory timeframes. Furthermore, the form verifies that services are provided according to the client's individual treatment plan.
The Director of Residential Programs will verify this information during the weekly clinical meetings by reviewing the electronic health record. The completed form requires signatures from the Director of Residential Programs, the assigned Counselor, and the Program Coordinator.
Lastly, copies of the completed forms will be sent to the Executive Director after the weekly clinical meetings.
This plan of correction will be fully implemented no later than July 30, 2026. |