INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted November 18-19, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Conewago Snyder was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on client and staff interviews along with a review of Monitor timesheets and the facility ' s Urinalysis Procedures for Drug & Alcohol Screens and Alcohol Breath Tests and Search Policies, the facility failed to ensure sufficient support staff for the safe operation of the project.
Monitors are responsible for performing client searches and alcohol breath testing on all clients returning to the facility from un-escorted sign-outs, as well to the resident population on a random or suspicion basis.
On October 26 the total client census was 35 with one Monitor working during the first shift.
On October 27 the total client census was 34 with one Monitor working during the first shift.
On November 7 the total client census was 36 with one Monitor working two hours alone during the second shift from 9pm to 11pm.
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Plan of Correction
The facility has hired additional monitor staff to increase coverage and ensure adequate staffing levels at all times. The Facility Director (FD) will review and approve all monitor schedules to ensure: Adequate staffing for client searches and breathalyzer testing during all shifts. All monitor staff will be re-trained on: Urinalysis, breathalyzer, and search procedures. The Facility Director will: Conduct weekly reviews of monitor schedules and timesheets. Verify compliance with minimum staffing ratios and coverage plan. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on client and staff interviews, along with a review of client charts and facility policies, the facility failed to follow two out of ten policies reviewed.
The facility failed to follow its Urinalysis Procedures for Drug & Alcohol Screens and Alcohol Breath Tests Policy which states that alcohol breath testing is conducted on all residents returning to the facility from un-escorted sign-outs.
Client #1 was admitted on 7/17/2025 and discharged on 11/2/2025. Chart documentation showed that on 8/31/2025 and 9/30/2025 the client refused to wait to get patted down by staff or breathalyzed after returning from outside meetings.
The facility failed to follow its Treatment Planning Policy which states that: 16) When a client successfully completes programming, all objectives are to reflect the accurate status of completion. 17) When a client leaves treatment unsuccessfully, all objectives are updated to reflect the accurate status and a note should be developed in the status description to indicate the client did not complete the goal as they were discharged unsuccessfully. 18) When a client leaves treatment against medical/facility advice, all objectives are updated to reflect the accurate status of the objective and a note entered into the status description to indicate as to why it was not completed.
This was not done in 2 out of 4 charts reviewed.
Client #1 was admitted to on 7/17/2025 and discharged on 11/2/2025. The discharge summary showed the client completed successfully. However, the most recent treatment plan update dated 10/21/2025 did not have all of the goals completed or signed off. Problem 1 Objectives 1, 2, and 4 were not completed. Problem 2 Objective 2 was not completed.
Client #2 was admitted on 7/28/2025 and discharged on 11/3/2025. The discharge summary showed the client completed successfully. However, the treatment plan update dated 10/6/2025 did not have all of the goals completed or signed off. Problem 1 Objectives 1 & 3 were not completed. Problem 2 Objectives 1, 3 and 4 were not completed.
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Plan of Correction
Effective 12/5/2025, Firetree amended its Urinalysis and Alcohol Breath Testing Policy to clearly define procedures and clinical response when a client refuses to submit to a urine screen or breathalyzer test. The policy now states:
"If you refuse to provide a urine sample or submit to a breathalyzer test when requested, the refusal will be addressed through appropriate clinical follow-up. If, based on your presentation and/or behavior, staff determine that the refusal poses a safety or security risk to the facility, you will not be permitted to leave the check-in area. Local authorities may be contacted and/or transportation to the Emergency Department will be arranged."
This policy revision clarifies staff authority, safety protocols, and required clinical action when a refusal occurs, ensuring consistent enforcement and protection of client and facility safety.
All direct care, clinical, and supervisory staff will be trained on the revised urinalysis and breathalyzer refusal procedure, including documentation requirements and safety response, during the next scheduled staff training on 1/29/26 and through supervisory review. Clients will receive an updated handbook on 1/30/26
All returns from un-escorted sign-outs will require immediate breathalyzer screening per policy. Any refusal will be documented in the client record and addressed through clinical follow-up. The Facility Director will conduct random audits of sign-out and screening documentation to verify consistent implementation.
All clinical staff will be re-educated on the Treatment Planning Policy requirements for updating objectives at discharge, including proper documentation for successful completion, unsuccessful discharge, and discharge against medical/facility advice. The Clinical Supervisor will conduct routine audits of discharge charts to verify compliance and will provide corrective coaching or retraining as needed. |
709.54(a)(3) LICENSURE Proper preparation of food
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(3) Proper preparation of food.
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Observations
The facility failed to follow its Food Service Policy which states that food service employees/workers (clients) are trained in the use of food service equipment and in safety procedures to be followed. The facility also failed to follow its Halfway House Resident Handbook, Section 6: Nutrition and Dining which states that on weekends, holidays, and days when the kitchen staff is not working, meals will be prepared by the residents themselves as a component of their life skills training, if the resident is ServSafe certified.
It was reported during client and staff interviews that Halfway House clients receive basic verbal instructions from the facility kitchen staff. However, no formal food service or safety procedure training has been provided by the facility. Most of the clients providing food services in the facility are not ServSafe certified. This is concerning as the Halfway House clients are often left alone to prepare and serve the meals for the Inpatient and Halfway House clients during week nights (dinner) and weekends (breakfast, lunch, and dinner) .
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Plan of Correction
On 12/5/25, Firetree revised its Food Service Policy to remove the requirement for ServSafe certification and has developed a standardized written Food Service and Safety Procedure that outlines proper food handling, equipment use, sanitation, and safety practices consistent with DDAP and Department of Health standards.
The revised policy and procedure will be formally introduced to all staff at the staff meeting on January 29, 2026, and to all clients during the community meeting on January 30, 2026.
The facility will implement a required instructional group focused on food service and safety procedures. This group will provide structured training to clients on proper food preparation, equipment use, sanitation, and safety expectations. Clients must successfully complete this group prior to being permitted to assist with any kitchen or food service duties.
The Facility Director will review client charts to ensure documentation of completion of the food service and safety training group prior to assignment to kitchen duties. The Facility Director will
also ensure staff are trained to enforce the revised procedures and will provide retraining as necessary.
Any client who fails to follow established food service and safety procedures will be immediately removed from kitchen duties and may be disqualified from further food service assignments until retraining is completed. Staff will be retrained as needed to ensure consistent supervision and enforcement of the procedures. |
709.54(a)(5) LICENSURE Personal hygiene
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(5) Personal hygiene for those in food preparation areas.
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Observations
Based on client and staff interviews, and a review of facility policies, the facility failed to follow its Food Service Policy. The Food Service Policy states that hair nets and beard covers will be worn at all times. It also states that all food service employees/workers (clients) that handle food during preparation and serving of food will use plastic disposable gloves.
It was reported during client and staff interviews that the Halfway House clients who provide the food service, when the kitchen staff are not there, are not consistently wearing hair nets or plastic gloves as per the facility ' s policy.
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Plan of Correction
Hair nets, beard covers, and disposable gloves will be relocated to all kitchen hand-washing stations to ensure immediate access prior to food handling. Clear, visible signage will be posted at each hand-washing station and food preparation area stating that all individuals involved in food preparation and serving must wear hair nets, beard covers (if applicable), and disposable gloves in accordance with facility policy and DDAP sanitation standards.
All staff will be re-trained on the Food Service Policy, personal hygiene requirements, and monitoring responsibilities during the scheduled staff meeting on January 29, 2026. Training will emphasize enforcement, documentation, and corrective action when non-compliance is observed.
All clients assigned to food service duties will be informed of the personal hygiene requirements and proper use of protective equipment during community meetings on January 30, 2026. Expectations and consequences for non-compliance will be reviewed.
The Facility Director will conduct routine spot checks during all meal preparation periods to ensure compliance. Any failure to follow personal hygiene and protective equipment requirements will be addressed immediately through retraining and policy review. |