INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 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, Conewago - Pottsville 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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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.
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Observations
Based on a review of personnel records, the facility failed to ensure that three of nine employees received a minimum of six four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.Employee # 7 was hired as the program monitor since May 23, 2022 and was due to have the communicable disease trainings no later than May 2024. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection.Employee # 8 was hired as the program monitor since June 20, 2022 and was due to have the communicable disease trainings no later than June 20, 2024. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection.Employee # 9 was hired as the cook since August 30, 2022 and was due to have the communicable disease trainings no later than August 30, 2024. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
TB/STD training will be conducted virtually on 8/21/2025. The three individuals listed are enrolled in this training. The Facility Director shall ensure that all three employees will attend this training on 8/21/2025 in order to be compliant with this standard. The Facility Director, as well as the Corporate Training Officer, and the Corporate Compliance Officer shall monitor compliance on an on-going basis beginning 8/21/2025. The Facility Director will create a training tracker in Excel that all track this mandatory training. The Corporate Compliance Officer will review this training tracker on a monthly basis to ensure compliance. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual written staff performance evaluation in one of six personnel records reviewed.Employee #1 was hired as the project director on September 26, 2022 and was a current employee at the time of the inspections. The last annual written staff performance evaluation documented in the record was dated August 11, 2023. This is a repeat citation from July 10, 2024 annual licensing renewal inspections.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Performance evaluations will be tracked using Firetree's HR management software Kronos. The Kronos software will notify all staff members when their evaluations needs to be completed. The Facility Director will pull a report of all past due evaluations every quarter and instruct staff to completed evaluation as soon as possible. For corporate staff the report will be monitored by the Corporate Director of Administration. |
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 the review of client records, the project 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 one of seven client records reviewed.Client #4 was admitted on May 28, 2025 and discharged on June 14, 2025. A release of information form for a local hospital signed by the client on May 28, 2025, did not specify the purpose of disclosure.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/14/2025, the Clinical Supervisor conducted a comprehensive training on the topic of informed and voluntary consents. Emphasis was placed on ensuring the correct boxes are checked for the disclosure of information contained in the client record that included the purpose of disclosure. The Clinical Supervisor will provide additional and continued trainings to all clinical staff regarding appropriate completion of consents. The Corporate Compliance Department will monitor the compliance of consent documentation as part of scheduled client chart audits beginning 8/6/2025. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include group progress notes entered within 72-hours of the date of service in five of seven records reviewed.Client #1 was admitted on May 21, 2025, and was a current client at the time of the licensing inspection. The record contained group progress notes for a session occurring on May 28, 2025 that was not documented until June 11, 2025; session occurring on May 30, 2025 that was not documented until June 13, 2025; session occurring on June 2, 2025 that was not documented until June 9, 2025; session occurring on June 15, 2025 that was not documented until June 26, 2025; session occurring on June 16, 2025 that was not documented until June 27, 2025; session occurring on June 25, 2025 that was not documented until July 8, 2025; session occurring on July 2, 2025 that was not documented until July 8, 2025; and, session occurring on July 5, 2025 that was not documented until July 11, 2025.Client #2 was admitted on June 4, 2025, and was a current client at the time of the licensing inspection. The record contained group progress notes for a session occurring on June 6, 2025 that was not documented until June 13, 2025; session occurring on June 11, 2025 that was not documented until June 17, 2025; session occurring on June 18, 2025 that was not documented until June 24, 2025; session occurring on June 15, 2025 that was not documented until June 26, 2025; session occurring on June 16, 2025 that was not documented until June 27, 2025; session occurring on June 30, 2025 that was not documented until July 3, 2025; session occurring on July 2, 2025 that was not documented until July 8, 2025; and, session occurring on July 5, 2025 that was not documented until July 11, 2025.Client #3 was admitted on June 11, 2025, and was a current client at the time of the licensing inspection. The record contained group progress notes for a session occurring on June 11, 2025 that was not documented until June 17, 2025; session occurring on June 18, 2025 that was not documented until June 25, 2025; session occurring on June 15, 2025 that was not documented until June 26, 2025; and session occurring on June 16, 2025 that was not documented until June 27, 2025.Client #5 was admitted on March 7, 2025 and was discharged on March 24, 2025. The record contained group progress notes for a session occurring on March 14, 2025 that was not documented until March 28, 2025; session occurring on March 20, 2025 that was not documented until March 25, 2025; and session occurring on March 22, 2025 that was not documented until March 28, 2025.Client #6 was admitted on February 19, 2025 and was discharged on March 21, 2025. The record contained group progress notes for a session occurring on February 21, 2025 that was not documented until March 5, 2025; session occurring on February 24, 2025 that was not documented until March 5, 2025; session occurring on March 5, 2025 that was not documented until March 11, 2025; session occurring on March 12, 2025 that was not documented until March 17, 2025; session occurring on March 17, 2025 that was not documented until March 28, 2025;and session occurring on March 19, 2025 that was not documented until March 25, 2025.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 7/14/2025 Clinical staff were retrained on Firetree's policy that group progress notes must be entered within 72 hours of the date of service. In regards to the content covered for the due dates for group progress notes staff were trained that group progress notes are due no later than 72 hours after the group session is concluded. To ensure future compliance the Clinical Supervisor will audit charts on a weekly basis to ensure they are completed in the proper timeframe. |