INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 2026, 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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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 project failed to ensure that two of six employees received a minimum of six hours of HIV/AIDS training using a Department approved curriculum within the regulatory timeframe.
Employee # 5 was hired as a monitor on September 11, 2023, and was currently in that position at the time of the inspection. Employee #5 was due to have the communicable disease training no later than September 11, 2025. Documentation showed that this employee did not receive the six hours of HIV/AIDS training at the time of the inspection.
Employee # 6 was hired as a cook on July 11, 2023, and was currently in that position at the time of the inspection. Employee #6 was due to have the communicable disease training no later than July 11, 2025. Documentation showed that this employee did not receive the six hours of HIV/AIDS training at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Employee #5 and Employee #6 will be enrolled in and complete the six-hour HIV/AIDS training available through the DDAP Training Management System no later than September 30th, 2026. Upon completion, the Facility Director will ensure that the training certificates are maintained in each employee's personnel record.
The Facility Director will complete an audit of the personnel and training records for all current employees and volunteers by August 14, 2026, to verify completion of the required six-hour HIV/AIDS training and four-hour tuberculosis, sexually transmitted diseases, and other health-related topics training within the timeframes established by 28 Pa. Code § 704.11(c)(1).
To prevent recurrence, the facility's training-tracking system will be updated by August 14, 2026, to include each employee's date of hire, position classification, required communicable-disease trainings, regulatory due dates, enrollment dates, and completion dates. The Facility Director will review the tracking system monthly and will initiate follow-up for any training that remains incomplete within 90 days of its required completion date.
The Facility Director will be responsible for implementation and continued monitoring of this plan. Compliance with communicable-disease training requirements will be reviewed monthly as part of the monthly in service training. |
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 plant inspection on July 14, 2026, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
When tested, the hot water in two client bathrooms was 122.8 degrees Fahrenheit.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that maintenance staff adjust the facility's hot water system so that the water temperature does not exceed 120 degrees Fahrenheit. The two client bathrooms identified during the inspection will be retested following the adjustment to verify compliance.
By August 7, 2026, maintenance staff will test the hot water temperature at all client and staff bathroom fixtures throughout the facility. The results will be documented on a water temperature log. Any fixture with a water temperature exceeding 120 degrees Fahrenheit will be immediately removed from use until the temperature is adjusted and verified to be compliant.
To prevent recurrence, maintenance staff will test and document hot water temperatures weekly for four weeks and monthly thereafter as part of the facility's routine physical plant inspection. The Facility Director will review and sign the inspection log monthly to verify that testing was completed and that all recorded temperatures remain at or below 120 degrees Fahrenheit. Any temperature exceeding the regulatory limit will be immediately reported to the Facility Director and corrected.
The Facility Director will be responsible for implementation and ongoing monitoring of this plan of correction. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of administrative documents, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident requiring the presence of police, fire or ambulance personnel.
An unusual incident that required the presence of law enforcement occurred on October 4, 2025. A written unusual incident report was not filed with the Department.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
Upon identification of the reporting omission, the Facility Director will submit a written unusual incident report to DDAP through the Event Reporting System for the October 4, 2025 incident no later than August 7, 2026. The report will identify the actual date of the incident and will note that it is being submitted after the required reporting timeframe. Documentation confirming submission will be maintained with the facility's administrative incident records.
At the next staff in-service training on August 27, 2026, the Facility Director will provide retraining regarding the unusual incident reporting requirements contained in 28 Pa. Code § 709.34. The training will emphasize that an event at the facility requiring the presence of police, fire, or ambulance personnel must be reported to DDAP within three business days.
To prevent recurrence, the Facility Director will review each internal incident report, tracked in the Facility's EMR, no later than the next business day to determine whether the incident is reportable to DDAP.
In the Facility Director's absence, a designated management staff member will be responsible for reviewing incidents and completing required submissions within the regulatory timeframe.
The Facility Director will be responsible for implementation and ongoing monitoring of this plan of correction. |
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, per facility policy, in six out of seven records reviewed.
Client #1 was admitted on May 20, 2026, and was a current client at the time of the licensing inspection. The record contained group progress notes for a session occurring on June 5, 2026, that was not documented until June 15, 2026; a session occurring on June 26, 2026, that was not documented until July 3, 2026; a session occurring on June 29, 2026, that was not documented until July 7, 2026; and a session occurring on July 6, 2026, that was not documented until July 11, 2026.
Client #2 was admitted on May 8, 2026, and was a current client at the time of the licensing inspection. The record contained group progress notes for a session occurring on June 3, 2026, that was not documented until June 9, 2026; a session occurring on June 5, 2026, that was not documented until June 15, 2026; a session occurring on June 29, 2026, that was not documented until July 6, 2026; and a session occurring on July 6, 2026, that was not documented until July 11, 2026. Additionally, the record contained an individual progress note for a session occurring on May 10, 2026, that was not documented until May 15, 2026.
Client #3 was admitted on May 19, 2026, and was a current client at the time of the licensing inspection. The record contained group progress notes for a session occurring on June 19, 2026, that was not documented until June 25, 2026; a session occurring on June 29, 2026, that was not documented until July 6, 2026; and a session occurring on July 6, 2026, that was not documented until July 11, 2026.
Client #4 was admitted on August 20, 2025, and was discharged on October 1, 2025. The record contained an individual progress note for a session occurring on September 26, 2026, that was not documented until October 1, 2026.
Client #6 was admitted on April 14, 2026, and was discharged on June 19, 2026. The record contained group progress notes for a session occurring on April 22, 2026, that was not documented until May 1, 2026; a session occurring on April 28, 2026, that was not documented until May 5, 2026; and a session occurring on April 2, 2026, that was not documented until May 5, 2026. Additionally, the record contained an individual progress note for a session occurring on April 24, 2026, that was not documented until May 1, 2026.
Client #7 was admitted on November 12, 2025, and was discharged on December 10, 2025. The record contained group progress notes for a session occurring November 28, 2025, that was not documented until December 4, 2025; and a session occurring on December 4, 2025, that was not documented until December 9, 2025. Additionally, the record contained an individual progress note for a session occurring on November 28, 2025, that was not documented until December 4, 2025.
This is a repeat citation from the July 17, 2025, annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director will review the progress note requirements with all clinical staff by August 10, 2026. Staff will be reminded that all individual and group progress notes must be entered into the client record within 72 hours of the date of service, as required by facility policy. Documentation of the training will be maintained.
Effective August 10, 2026, the Facility Director will review the task board within the electronic medical record weekly for 90 days to identify incomplete or overdue individual and group progress notes. Any identified documentation deficiencies will be addressed with the responsible staff member and completed as a late entry without backdating.
After the initial 90-day monitoring period, compliance with progress note completion will be reviewed as part of the facility's routine monthly clinical record review. Continued documentation deficiencies will be addressed through supervision and corrective action, as appropriate.
The Facility Director will be responsible for implementing and monitoring this plan and ensuring continued compliance. |