INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 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 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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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 one of six employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 6 has been in the program monitor since April 11, 2022 and was due to have the communicable disease trainings no later than April 11, 2024. There was no documentation that the employed received the communicable disease trainings at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 has completed HIV/AIDS training on 7/3/2025 and is scheduled to attend TB/STD training on 8/21/2025.
All staff will be reminded of 704.11(c) mandatory communicable disease training requirement during monthly staff meeting on 8/19/2025.
Employee training requirements will be tracked on a monthly basis by corporate trainer, clinical supervisor and assistant director, respectively, to ensure that all employees receive mandatory trainings within the required time frame."
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, four weeks of staff schedules and the Staffing Requirement Facility Summary Report (SRFSR), the project failed to ensure that a sufficient number of staff persons trained in CPR and first aid was onsite during the project's hours of operation.
The facility ' s hours of operation are 24 hours a day, 7 days a week. There were no staff members with a current CPR/First Aid Certificate documented in their personnel record between the hours of 3:00 pm and 11:00pm on the following dates: May 11, 2025, May 17, 2025, May 18, 2025, May 25, 2025, May 31, 2025, June 1, 2025 and June 7, 2025. Additionally, there were no staff members with a current CPR/First Aid Certificate documented in their personnel record between the hours of 7:00 pm and 11:00pm on the following dates: May 16, 2025, May 23, 2025, May 28, 2025, May 30, 2025, June 4, 2025, and June 6, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 7/20/2025, indicators have been added to identify staff with appropriate CPR/First Aid training for each shift to ensure properly trained staff are scheduled on each shift to comply with 704.11(c)(2) CPR certification and first aid training.
Employee training requirements will also be tracked on a monthly basis by corporate trainer, clinical supervisor and assistant director, respectively, to ensure that all employees receive mandatory trainings within the required time frame. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of fire drills conducted from August 2024 through June 2025, the facility failed to conduct unannounced monthly fire drills for the months of November 2024 and April 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 8/2/2025 an annual calendar has been created, with scheduled monthly fire drills assigned for each shift, to ensure compliance with 705.10. (d) (1) Fire Drills.
Monthly dates and reminders will be tracked by assistant director. |
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 the July 8, 2024 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure 709.26(b) 3 Personnel management and to prevent continued lapse in Employee #1 annual review, Kronos system will send a reminder 30 days prior to the due date of employee evaluation and will be tracked and monitored by Corporate Director of Administration. |
709.28 (c) 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.
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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 in one of seven client records reviewed.
Client #2 was admitted on May 14, 2025 and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
This is a repeat citation from the July 8, 2024 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will receive corrective training regarding 709.28 (c) Confidentiality by reviewing all the parts of a valid ROI, specifically focusing on the importance of obtaining proper consent prior to contacting any outside entity, during monthly staff meeting on 8/19/2025.
To ensure continued compliance, monthly chart audits will be conducted by the assigned counselor, the Clinical Supervisor, and the corporate compliance team.
Client#2 signed consent on 6/26/2025.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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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 specific information to be disclosed in one of seven client records reviewed.
Client #6 was admitted on December 19, 2024 and was discharged December 27, 2024. A release of information form for the emergency contact, signed by the client on December 20, 2024, did not specify the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/19/2025, during monthly all staff meeting, staff will receive corrective training on 709.28 (c) (2) Confidentiality by reviewing all the parts of a valid ROI; specifically, they will be retrained on choosing the appropriate information that is to be disclosed.
To ensure continued compliance, monthly chart audits will be conducted by the assigned counselor, the Clinical Supervisor and the corporate compliance team. |
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 #5 was admitted on October 15, 2024 and discharged on November 19, 2024. A release of information form for a probation officer, signed by the client on October 15, 2024, 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
By 8/19/2025, during monthly all staff meeting, staff will receive corrective training on 709.28 (c) (3) Confidentiality by reviewing all the parts of a valid ROI; specifically, they will be retrained on choosing the appropriate purpose of the ROI.
To ensure continued compliance, monthly chart audits will be conducted by the assigned counselor, the Clinical Supervisor and the corporate compliance team. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one applicable client record reviewed.
Client #7 was admitted on January 8, 2025 and was involuntarily discharged on January 11, 2025. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 8/19/2025, during monthly all staff meeting, staff will receive corrective training on 709.33 (a) Notice of
termination to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project as well as the reason for termination.
To ensure continued compliance all client's that are involuntarily discharged from the project, their files will be checked for the notice of termination during monthly chart audits conducted by the Clinical Supervisor and the corporate compliance team. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and the project ' s policies and procedures, the project failed to document a complete client record on an individual that included case consultation notes in three of five applicable client records reviewed. Per the projects policy, one case consultation note is to be documented in the record on the 14th day of treatment.
Client #1 was admitted on May 7, 2025 and was active at the time of the inspection.
Per the projects policy, a case consultation note was due by May 19, 2025; however, a case consultation note was not documented in the client record until June 12, 2025.
Client #2 was admitted on May 14, 2025 and was active at the time of the inspection.
Per the projects policy, a case consultation note was due by May 28, 2025; however, a case consultation note was not documented in the client record until June 24, 2025.
Client #4 was admitted on October 2, 2024 and was discharged December 2, 2024.
Per the projects policy, a case consultation note was due by October 16, 2024; however, a case consultation note was not documented in the client record until November 9, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 8/1/2025, during weekly clinical supervision, all clinical staff will receive corrective training on 709.53 (a) (8) Case Consultations. Clinical staff will be reeducated on the company policy that case consults must be completed within 15 days of client admission.
To ensure continued compliance, clinical team will meet weekly to review case consults. Additionally, their files will be checked during monthly chart audits conducted by the Clinical Supervisor and the corporate compliance team. |