INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 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 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 facility failed to ensure that five of nine 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 # 5 was hired as the program monitor on March 13, 2023 and was still in that position. Employee #5 was due to have the communicable disease trainings no later than March 13, 2025. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection.
Employee # 6 was hired as the program monitor since March 20, 2023 and was still in that position. Employee #6 was due to have the communicable disease trainings no later than March 20, 2025. There was no documentation that the employe received the communicable disease trainings at the time of the inspection.
Employee # 7 was hired as the program cook since October 20, 2022 and was still in that position. Employee #7 was due to have the communicable disease trainings no later than October 20, 2024. There was no documentation that the employee received the communicable disease trainings at the time of the inspection.
Employee # 8 was hired as the program monitor since July 11, 2023 and was still in that position. Employee #8 was due to have the communicable disease trainings no later than July 11, 2025. There was no documentation that the employee received the communicable disease trainings at the time of the inspection.
Employee # 9 was hired as the program monitor since May 23, 2022 and was still in that position. Employee #9 was due to have the communicable disease trainings no later than May 23, 2024. There was no documentation that the employe 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
Firetree has scheduled a staff training for August 21, 2025. As many staff members as operationally possible will attend the training to ensure compliance with required standards. The Facility Director will coordinate with the Corporate Training Director to ensure all applicable staff are scheduled for and attend required trainings within the require time frames. Attendance for the August 21 training will be documented and maintained in the central training tracker managed by the Corporate Training Director. The Facility Director will conduct semi-annual reviews of the training tracker to verify that staff remain in compliance with training standards and deadlines. Any identified gaps in training completion will be addressed through direct follow-up with staff. Training compliance and expectations will be reviewed during staff supervision and monthly staff meetings. The Facility Director will be responsible for ongoing compliance |
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 a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client #6 was admitted to the inpatient non-hospital rehabilitation level of care on January 28, 2025 and was discharged Against Staff Advice (AMA) on February 12, 2025. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 12, 2025, all clinical and monitor staff received retraining on the facility's AMA discharge policy, specifically emphasizing the requirement to notify the client's emergency contact within 12 hours of an AMA discharge. The retraining included documentation expectations in the client record to reflect this communication. The Facility Director will ensure that AMA discharge procedures are reviewed during monthly staff meetings for the next 90 days. The discharge checklist has been updated to include a mandatory item for emergency contact notification within 12 hours of an AMA discharge. Staff must document the time and method of contact (or reason for no contact) in the client's record. Any AMA discharge will be reviewed by the Facility Director within 24 hours to verify policy compliance. Discrepancies identified by the compliance team during chart reviews will be immediately communicated to the Facility Director, who will follow up with the responsible staff member for correction and retraining as needed. New clinical and monitor staff will receive training on AMA discharge protocols during onboarding. |
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.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 15th, 2025 Firetree has implemented additional safeguards to ensure annual staff evaluations are completed and documented timely. All staff performance evaluations will be tracked through Firetree's HR management software, Kronos. The system will generate automated reminders to staff and supervisors when evaluations are due. Facility Directors will run quarterly reports through Kronos to identify and address any past due evaluations immediately. For corporate-level staff, the Corporate Director of Administration will review the same reports to ensure compliance at the administrative level. |
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 the facility's policy, in five of seven applicable records reviewed.
Client #1 was admitted on June 23, 2025 and was a current client at the time of the inspection. The record contained group counseling session progress notes for sessions occurring on June 30, 2025, July 1, 2025, and July 2, 2025, that were not documented until July 7, 2025.
Client #2 was admitted on June 24, 2025 and was a current client at the time of the inspection. The record contained group counseling session progress notes for sessions occurring on June 30, 2025, July 1, 2025, and July 2, 2025, that were not documented until July 7, 2025.
Client #3 was admitted on June 13, 2025 and was a current client at the time of the inspection. The record contained group counseling session progress notes for sessions occurring on June 30, 2025, and July 1, 2025, that were not documented until July 7, 2025. Additionally, the record contained a group counseling session progress note for a session occurring on June 26, 2025, that was not documented until July 1, 2025.
Client #4 was admitted on September 30, 2024 was discharged on November 4, 2024. The record contained progress notes for group counseling sessions occurring on October 3, 2024, that was not documented until October 29, 2024; session occurring on October 4, 2024, that was not documented until October 16, 2024; and session occurring on October 7, 2024, that was not documented until October 14, 2024.
Client #7 was admitted on November 19, 2024 was discharged on December 20, 2024. The record contained progress notes for group counseling sessions occurring on November 27, 2024, that was not documented until December 1, 2024; session occurring on December 12, 2024 that was not documented until December 17, 2024; and session occurring on December 16, 2024 that was not documented until December 26, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On August 12, 2025, all clinical staff were retrained on the facility's documentation policy, including the requirement that group counseling session progress notes be entered into the client record within 72 hours of the service date. Clinical Supervisor will conduct weekly random audits of group notes to ensure compliance with the 72-hour documentation requirement. Non-compliance will be addressed through immediate supervision and retraining. Documentation expectations and timelines will be reviewed with all new clinical hires during onboarding and reinforced in monthly clinical supervision. The Facility and/or Clinical Supervisor will be responsible for ongoing compliance. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of client records, the project failed to document a complete client record on an individual that included follow-up contact within seven days post discharge, per facility policy, in two of four applicable records reviewed.
Client #4 was admitted on September 30, 2024 was discharged on November 4, 2024. There was no follow-up contact information documented in the client record seven days post discharge.
Client # 5 was admitted on February 24, 2025 and was discharged on April 2, 2025. There was no follow-up contact information documented in the client record seven days post discharge.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On August 12, 2025, all clinical and case management staff were retrained on the facility's policy requiring follow-up contact within seven calendar days of a client's discharge. The retraining included proper documentation procedures for recording follow-up attempts and outcomes in the client record. The Facility Director or designee will conduct biweekly audits of all discharges to ensure that follow-up contacts are completed and properly documented. Any missed follow-ups will be reviewed with the responsible staff member and addressed with retraining or corrective action as needed. Follow-up procedures and documentation standards will be reviewed during monthly staff meetings and all new hire onboarding. The Facility and/or Clinical Supervisor will be responsible for ongoing compliance. |