INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 22, 2021 & December 20, 2021 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on review of the facility staff summary sheet and personnel records, the facility failed to ensure that staff persons and volunteers shall receive a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first two years of employment.
Staff #4 was hired as a house coordinator on November 4, 2019, however at the time of the inspection had not yet received her four hours of tuberculosis, sexually transmitted diseases and other health related topics training.
These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
1. Project Director will ensure that all staff receive HIV/AIDS, Sexually Transmitted Diseases, Tuberculosis and other Health related topic trainings within the first two years from employment date.
2. Employee #4 is no longer employed at Nasr Consultants-Residential. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120F.
The bathroom in the A wing had a water temperature of 140F, the bathroom in B wing has a temperature of 140F and the bathroom identified as B3 had a temperature of 140F.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
1. Project Director called facility Maintenance to inspect furnace and water heater on 12/20/2021.
2. Maintenance personnel trained and instructed Project Director on monitoring Temperature Dial on Furnace and water heater on 12/20/2022.
3. Project Director assisted Maintenance Personnel returned to Nasr-Residential by taking water temperature in Kitchen and Bathroom sinks in A an B Wing which read 115F on 12/20/2022.
4 Project Director will purchase water thermometer to check water temperatures within the program by 2/9/2022.
2. Project Director will create and implement temperature log and train all Staff to conduct water temperature checks by 2/9/2020 |
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.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that the food is at or below 40 hot food at or above 140 and frozen food at or below 0 were no thermometers in either one of the freezers that are in the basement of the facility.
These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
1. Project Director will purchase thermometers for all refrigerators and freezers to ensure that food is stored at appropriate temperature by 2/9/2022.
2. Project Director will create and implement temperature logs for refrigerator and freezer by 2/9/2022.
3. Project Director will train all Staff to monitor and document on temperatures on Log by 2/9/2022.
|
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.
|
Observations
Based on a review of the facility's staff summary sheet and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #2 was hired on April 5, 2021; however, did not receive emergency training until May 19, 2021.
This was reviewed with the staff during licensing inspection process.
|
Plan of Correction
1. Project Director will ensure that all hired employees will receive Emergency Training within a week of employee date of hire. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to assure that the client was offered a copy of the consent on all seven client records reviewed.
These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
1. Project Director will implement section on Consent Form in Nasr Consultants Electronic Health Records which offers client copy of Consent for election or rejection by 2/9/2022. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of the project's policy and procedures manual and client records, the project failed to include that the client may not be discriminated against based on creed. The documentation making the client aware of their rights did not include creed.
These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
1. Project Director will revise Nasr Consultant's Policy and Procedure Manuel, Statement of Client's Rights and Responsibilities to include that client may not be discriminated against based on creed. |