INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on December 12, 2013 and an on-site complaint investigation conducted on December 16, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of both the off-site and on-site complaint investigation, Conewago Place 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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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on conversation and documentation provided by the facility, they were overcapacity on 12/5/13.
The findings include:
A phone call was received on 12/12/13 informing the Department that the facility was over capacity on 12/5/13. Contact was made with the facility on 12/12/13 requesting further information. The facility faxed documentation from 12/5/13 which showed their client count at 56. The current capacity is 55. Discussion with the facility and further review of documentation on 12/16/13 further confirmed that the facility was over capacity on 12/5/13.
The Facility Director confirmed the findings.
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Plan of Correction
The complaint #A029 was reviewed with our governing body of Firetree, Ltd. on 12/12/13.
The Chief Operating Officer of Firetree, Ltd. initiated a verbal directive to all Firetree facility directors on 12/17/13 stating the following: "Under no circumstance should any Firetree facility go over their licensed capacity in the future for any reason". The directive also clarified that in the event that any client from a Firetree facility is placed outside the facility for any reason, that client's bed should be held and the slot not filled until such time as we are assured that the client is not returning to the facility.
The Facility director of Conewago Place will review the facility's census with the governing body on a daily basis beginning on 12/19/13 to ensure ongoing compliance.
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