INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9-10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Snug Harbor Rehabilitation and Recovery, LLC 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 employees received the minimum of at least 6 hours of HIV/AIDS and 4 hours of TB/STD and other health related topics within the first two years of employment in two of three records.
Staff #5 was hired as a case manager on January 26, 2023 and still employed. Communicable disease training was due to be completed by January 26, 2025 but TB/STD training was not completed at the time of the inspection.
Staff #6 was hired as a house monitor on December 7, 2022 and still employed. Communicable disease training was due to be completed by December 7, 2024 but TB/ STD was not completed at the time of the inspection. Additionally, HIV/AIDS training was not completed until November 21, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 23, 2023, December 7, 2023, and December 10, 2024 licensing renewal inspections.
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Plan of Correction
First staff member completed the required training on 1/8/26. The second staff member is scheduled to attend and complete their training on 1/20/26. Once completed, all staff members will be in compliance with all DDAP required trainings.
Program Director is responsible for monitoring training compliance and maintaining documentation. This facility implemented a training tracking log to monitor required trainings, due dates, and completion dates for all staff to prevent recurrence and will be reviewed monthly until full compliance is met and will be reviewed quarterly thereafter. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a review of the physical plant, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department of fire extinguisher company.
The fire extinguishers in unused offices in both cottage 1 and cottage 3 were both last serviced November 2024 and due to be inspected by November 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All fire extinguishers in the facility were checked, the ones out of date were brought into compliance on 12/29/25. The Operations Manager is responsible for oversight. It was notated in operations manager's most recent supervisory session that it will be their responsibility to maintain compliance at all times. Compliance will be monitored through annual verification of inspection tags during routine facility safety checks. |
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 a review of fire drill records and staff interviews, the facility failed to conduct monthly fire drills.
Fire drill logs were reviewed from December 2024 to November 2025. Fire drills were conducted in cottage 1 and detox for all applicable months but cottage 3 drills were not conducted during the following months: December 2024, January 2025, February 2025, April 2025, May 2025, June 2025, September 2025, October 2025, November 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 10, 2024 licensing renewal inspections.
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Plan of Correction
The facility reviewed fire drill records and immediately resumed conducting monthly unannounced fire drills in all applicable buildings including Cottage 3. All completed drills are documented in fire drill logs.
The Operations Manager is responsible for oversight. Fire drill logs will be reviewed monthly to ensure ongoing compliance. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to utilize alternate exit route during fire drills.
Fire drill logs were reviewed from December 2024 to November 2025. The residential program utilized " south exit " , and the detoxification program utilized " north exit " during every drill reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility issued a memo to all staff informing them that any time there is a fire drill, they need to utilize alternating exits during fire drills. All staff acknowledged by signing.
The Operations Manager is responsible for oversight and ensuring fire drills are documented properly. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. The facility had an unusual incident occur on July 6, 2025 which involved a physical assault. The facility has not submitted a written unusual incident report to the Department at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Supervisory staff will be responsible for reporting any unusual incidents to DDAP. All supervisory staff were informed of this and were given login and password information and instruction on how to accurately report appropriate unusual incidents to DDAP.
The Program Director is responsible for oversight. Incident reports and submission timelines will be reviewed during monthly management meetings to ensure compliance. |
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 a review of administrative information, the facility failed to inform the Department of an unusual incident within the required three days. The facility had unusual incidents occur on May 3, June 11, June 13, August 11, August 20, September 5, September 21, and November 29, 2025 which involved an ambulance on site not reported to DDAP. Additionally, the fire department was on premise October 26, 2025 which was not reported to DDAP.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Supervisory staff will be responsible for reporting any unusual incidents to DDAP. All supervisory staff were informed of this and were given login and password information and instruction on how to accurately report appropriate unusual incidents to DDAP.
The Program Director is responsible for oversight. Incident reports and submission timelines will be reviewed during monthly management meetings to ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for mandatory communicable disease training was submitted and approved by the Department for the March 23, 2023, December 7, 2023, and December 10, 2024 annual licensing inspections. Communicable disease training was again found to be a deficiency in the December 10, 2025 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director has conducted a review of all previously approved POCs related to licensing inspections.
A POC compliance log has been created to track each approved POC, required corrective actions, responsible party, due dates, and evidence of completion.
All active POC have been reviewed by the Executive Director and required corrective actions will be been verified and documented as completed as of 2/2/26.
To ensure all approved POCs are implemented and maintained the Executive Director is designated as the sole individual responsible for oversight, implementation, and monitoring of all Plans of Correction approved by the Department.
Upon approval of any POC, the Executive Director will review the POC in full, assign responsibility for each corrective action, establish monitoring checkpoints to ensure continued compliance. Approved POC will remain active monitoring items until verified as sustained, not simply until correction is completed.
The facility will implement the following monitoring process:
1. All approved POCs will be maintained in a centralized POC file.
2. Compliance with each POC will be reviewed during monthly management meetings.
3. The Executive Director will conduct quarterly compliance audits to verify that approved corrective actions continue to be followed.
4. Prior to each annual licensing inspection, a formal pre-inspection compliance review will be completed to confirm all approved POCs remain in effect, required actions are being followed, documentation is available for review.
The facility will achieve full compliance with this POC as of 2/2/26 and will ensure ongoing adherence to all approved POCs moving forward.
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