INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2026, 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on June 30, 2026, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
When tested, the hot water in the bathrooms of client rooms 2 and 10 was 122.2 degrees Fahrenheit.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By August 18, 2026, Weekly Fire Safety and Sanitation form will be updated to require testing at three locations instead of one. The form will include specific instructions for conducting the test to allow the water to run until the temperature stabilizes before taking a reading.
The Facility Director or designee will review the completed form prior to signing and ensure that Maintenance is notified to make any necessary adjustments whenever water temperatures fall above 120. |
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 notifying emergency contacts within twelve hours if a client leaves against staff advice in two of two applicable records reviewed.
Client #5 was admitted to the inpatient non-hospital residential level of care on January 21, 2026, and was discharged Against Staff Advice (ASA) on February 22, 2026. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.
Client #6 was admitted to the inpatient non-hospital detox level of care on January 12, 2026, and was discharged Against Staff Advice (ASA) on February 17, 2026. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The counselor assigned to Client #5 is no longer employed by Firetree, due to continual failure to comply with program policies and procedures.
Client #6 was transferred to another Firetree facility on January 22, 2026. Clinical documentation indicates that contact was made with the EC within the time frame required.
By August 18, 2026, during all staff meeting, all staff will be retrainined on proper steps that need to be taken when a client leaves the facility against advise.
Specifically, all staff will be provided step by step instructions to help guide the process to prevent continued lapses in EC notification.
Further, all clinical staff will be retrainined regarding their requirements to contact emergency contact within 12 hours of AMA/ASA, by August 7, 2026. |
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 records reviewed.
Client #7 was admitted on October 22, 2025, and was discharged on December 22, 2025. Facility staff communicated with the client ' s aftercare provider on December 22, 2025; however, a release of information was not documented in the client record prior to the disclosure.
This is a repeat citation from the July 8, 2024, and July 2, 2025, annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The counselor assigned to Client #7 is no longer employed by Firetree, due to continual failure to comply with program policies and procedures.
By August 18, 2026, during all staff meeting, all staff will be retrainined on proper steps needed to complete a full consent.
Specifically, all staff will be retrainined to confirm all parts of a consent are completed accurately, and signed by all parties prior to making contact with outside sources.
Further, all clinical staff will be retrainined regarding the steps needed to confirm a consent is complete and valid, by August 7, 2026.
Finally, quarterly reviews will be conducted with the clinical staff by the clinical supervisor to ensure continued compliance and prevent repeated plan of correction violations.
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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 # 1 was admitted on May 13, 2026, and was active at the time of the inspection. A release of information form for a hospital signed by the client on May 13, 2026, did not specify the purpose of disclosure.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
By August 18, 2026, during all staff meeting, all staff will be retrainined on proper steps needed to complete a full consent.
Specifically, all staff will be retrainined to confirm all parts of a consent are completed accurately, and signed by all parties prior to making contact with outside sources.
Further, all clinical staff will be retrainined regarding the steps needed to confirm a consent is complete and valid, by August 7, 2026.
Finally, quarterly reviews will be conducted with the clinical staff by the clinical supervisor to ensure continued compliance and prevent repeated plan of correction violations.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a discharge summary within seven days of discharge, per facility policy, in two of four applicable client records reviewed.
Client #4 was admitted on May 21, 2026, and was discharged on June 11, 2026. The discharge summary was due to be completed by June 18, 2026; however, it was not documented in the client record until June 26, 2026.
Client #5 was admitted on January 21, 2026, and was discharged on February 22, 2026. A discharge summary was not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The counselor assigned to Client #4 is no longer employed by Firetree.
The counselor assigned to Client #5 is no longer employed by Firetree, due to continual failure to comply with program policies and procedures.
By August 7, 2026, all clinical staff will be retrainined regarding due dates and expectations for completing required documentation timely.
Specifically, due dates for all clinical documentation will be reviewed.
Finally, quarterly reviews will be conducted with the clinical staff by the clinical supervisor to ensure continued compliance and prevent repeated plan of correction violations.
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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 and administrative information, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the Julu 8, 2024 and July 2, 2025, annual licensing inspections. Obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record, was again found to be a deficiency in the June 30, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 18, 2026 deficiencies will be discussed with all staff to ensure future compliance.
Further, quarterly reviews will be conducted with the clinical staff by the clinical supervisor to ensure continued compliance and prevent repeated plan of correction violations. |