INITIAL COMMENTS
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This report is a result of an on-site licensure complaint investigation 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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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 facility grievances, the facility failed to document the outcomes of patient grievances within guidelines established by the facility's policy and procedures manual. The facility's policy and procedures manual states that the outcome of client grievances will be documented in a progress note in patient records.
A review of several client grievances revealed that the outcomes of patient grievances were not being documented.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
On August 12, 2025, all clinical and administrative staff were retrained on the proper grievance documentation procedures, with emphasis on the requirement to document grievance outcomes in the client's progress notes. The retraining included a review of the facility's policy and procedures manual, highlighting the importance of timely and accurate documentation to ensure compliance and transparency in the grievance resolution process. The Facility Director will oversee ongoing compliance by conducting monthly audits of all submitted grievances to verify that outcomes are being properly documented in the client record. Any identified omissions will result in immediate follow-up with the responsible staff member for corrective action and additional retraining, if necessary. All physical grievance forms will have a written response with date of resolution, if available. Physical forms will be maintained for retention in accordance with Firtree's document retention policy. Grievance documentation procedures will also be reviewed during staff meetings on a quarterly basis to reinforce expectations. |
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
Based on a review of the facility's policy and procedures, the facility failed to update it's food preparation policy to include the duties and responsibilities of patients working in the kitchen.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
On August 8, 2025, Firetree's Policy Committee updated policy 4-010 Food Service to include definitions outlining the duties and responsibilities of patients working in the facility kitchen. The revised policy will be distributed to all staff through Firetree's policy management system, Relias. All staff will be required to review and electronically acknowledge the updated policy within 90 days of distribution. The Facility Director will conduct a compliance check at the end of the 90-day period to ensure all staff have completed the acknowledgment. Any employee who has not acknowledged the policy will be followed up with directly and required to complete the review immediately. |
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 a review of the facility's policy and procedures, the facility failed to update it's personal hygienne for those in food preparation areas, policy to include patients working in the facility kitchen.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
On August 8, 2025, Firetree's Policy Committee updated policy 4-010 Food Service to include definitions outlining the duties and responsibilities of patients working in the facility kitchen including hygiene requirements. The revised policy will be distributed to all staff through Firetree's policy management system, Relias. All staff will be required to review and electronically acknowledge the updated policy within 90 days of distribution. The Facility Director will conduct a compliance check at the end of the 90-day period to ensure all staff have completed the acknowledgment. Any employee who has not acknowledged the policy will be followed up with directly and required to complete the review immediately. |