INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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 (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.
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Observations
Based on a physical site inspection on August 19, 2021, the facility failed to ensure that hot water temperatures did not exceed 120 degrees Fahrenheit.
The water temperature in the men's bathroom read 132 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning at time of this response, 9/16/1021, the Facility Maintenance staff shall measure, adjust if necessary, and record water temperatures throughout the facility to ensure temperatures do not exceed 120 degrees Fahrenheit. Oversight of this process will be conducted monthly by the Facility Director and Corporate Compliance Department. |
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
During a review of fire drill records on August 19, 2021, the facility failed to include the number of persons in the facility at the time of the drill on the April, May, June and July 2021 fire drills that were completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning at time of this response, 9/16/1021, the Facility Director will ensure that fire drill documentation contains all required criteria, including the number of individuals in the facility at time of the drill. Oversight of this process will be conducted monthly by the Facility Director and Corporate Compliance Department. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an inspection completed on August 19, 2021, the project failed to obtain the services of an independent certified public accountant for an annual 2020 financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
he current financial audit is in progress and is anticipated to be completed and received from the independent certified public accountant agency by 9/30/2021. Firetree, Ltd. shall ensure that future annual financial audits do not exceed a one year timeframe. |
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 seven client records on August 19, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in six out of seven client records reviewed.
Client #1 was admitted on June 30, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 14, 2021, and the next update was due no later than August 13, 2021; however, the next update not completed until August 17, 2021.
Client #2 was admitted on June 30, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 18, 2021 and the next update was due no later than August 17, 2021; however, was not completed until August 21, 2021.
Client #4 was admitted on June 28, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 12, 2021, and the next update was due no later than August 11, 2021; however, the next update was not completed until August 13, 2021
Client #5 was admitted on January 14, 2021 and was discharged on April 27, 2021. A treatment plan update was completed on January 29, 2021 and the next update was due no later than February 28, 2021; however, the next update was not completed until March 2, 2021.
Client #6 was admitted on February 24, 2021 and was discharged on April 27, 2021. A treatment plan update was completed on March 11, 2021 and the next update was due no later than April 11, 2021; however, the next update was not completed until April 12, 2021.
Client #7 was admitted on March 25, 2021 and was discharged on June 17, 2021. A treatment plan update was completed on April 8, 2021 and the next update was due no later than May 8, 2021; however, the next update was not completed until May 11, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will be trained on required treatment plan update review timeframes by 9/24/2021. The training will provide clarity that the review of treatment and rehabilitation plans cannot exceed 30 days. The anchoring of review dates had been based upon admission dates, and this anchoring to admission date will no longer occur. Beginning on 09/20/21, Clinical team will begin auditing charts on a weekly basis to monitor at the facility level. Corporate Clinical Director will audit charts for this facility on a weekly basis to identify and correct any deficiencies. The Compliance Department will audit charts on a weekly basis as well beginning on 09/20/21. |