INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York 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 the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 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.
Employee #5 was hired as a counselor on January 13, 2025. His training was due no later than January 13, 2026; however, his HIV/AIDS was not completed until February 3, 2026 and his TB/STD training was not completed until February 24, 2026.
Employee #8 was hired as an Office Manager on November 18, 2022. Her training was due no later than November 18, 2024; however, her TB/STD training was not completed as of the time of the inspection.
Employee #9 was hired as BHA on March 13, 2023. Her training was due no later than March 13, 2025; however, her TB/STD training was not completed as of the time of the inspection.
Employee #10 was hired as a BHA on June 12, 2022. Her trainings were due no later than June 12, 2024; however, none was completed as of the time of the inspection.
Employee #11 was hired as a BHA on November 4, 2022. Her training was due no later than November 4, 2024; however, her TB/STD training was not completed as of the time of the inspection.
Employee #12 was hired as a BHA on September 7, 2021. Her trainings were due no later than September 7, 2023; however, none was completed as of the time of the inspection.
Employee #13 was hired as a BHA on January 13, 2024. Her training was due no later than January 13, 2026; however, none was completed as of the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Full audit of all current staff trainings has been completed and all current staff that are missing HIV/AIDS and TB/STD have been identified. An established deadline date of May 7th, 2026 has been given to all employees missing necessary trainings to either complete on-demand trainings available or be signed up for in person or virtual trainings.
An Onboarding Checklist for all new staff hired has been created, specifically including the first-year trainings required. Clinical Supervisor will be in charge of onboarding checklist for new counselors and BHA Supervisor will be in charge of onboarding checklist for new direct care staff. Checklist will be turned over to Facility Director when completed. All first year trainings are required to be completed or scheduled within their first 90 days. BHA Supervisor and Clinical Supervisor will set 30, 60, and 90 day reminders in calendar for their new staff to monitor training progress. Monthly audit of all staff training records will be monitored by Facility Director, who will be responsible for implementation and ongoing compliance. Full compliance will be achieved by July 10th, 2026. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential 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, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. The first floor and second floor bathroom's hot water was recorded at 130 degrees.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon identification of the issue, the water temperature was immediately adjusted down. All sinks were tested to confirm compliance.
BHA Supervisor has created and implemented a daily water temperature log for all sinks. If water temperature exceeds 120 degrees, staff will immediately adjust the temperature down. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection, the facility failed to clearly indicate exits by the use of signs in the second basement exit.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Exit signs in the basement were posted by maintenance to clearly identify all exits. All exit routes were inspected to ensure visibility and proper placement.
Monthly facility safety inspections have been updated to include exit signs on every level of the building.
BHA Supervisor conducts a weekly walkthrough of the building. Regional Risk Manager conducts their own walkthrough once a month. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the October, 2025 through February, 2026 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill on the October, 2025 through January, 2026 logs.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 2, 2024, February 13, 2025 and September 25, 2025 licensing inspections.
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Plan of Correction
BHA Supervisor and Office Manager, who are responsible for conducting drills were re-educated on proper procedures and documentation requirements. All fire drills conducted in 2026 have been reviewed and correctly marked. BHA Supervisor and Office Manager will continue to be in charge of all upcoming monthly drills and sending them monthly to the Regional Risk Manager who will be the last staff member to review all drills. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include, but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of six applicable records reviewed.
Client #9 was admitted on November 11, 2025 and discharged on January 29, 2026. A comprehensive treatment plan was developed on November 26, 2025 with no type or frequency identified.
Client #11 was admitted on December 24, 2025 and discharged on February 23, 2026. A comprehensive treatment plan was developed on January 5, 2025 with no type or frequency identified.
Client #13 was admitted on February 9, 2026 and discharged on March 23, 2026. A comprehensive treatment plan was developed on March 3, 2025 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A comprehensive audit of all active client treatment plans was conducted and updated immediately to include type of services, frequency of services, and evidence of client involvement in development of the plan.
All clinical staff have been re-trained on treatment planning. Weekly audits will be conducted to ensure every current active client's treatment plan includes type and frequency are documented and that client's signatures are present. Clinical Supervisor and Facility Director will be in charge of conducting the weekly audits, the Regional Risk Manager will also be involved in client chart audits for any oversights. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in six out of seven records reviewed.
Client #1 was admitted on September 2, 2025 and discharged on October 15, 2025. A comprehensive treatment plan was developed on September 2, 2025 with no type or frequency identified.
Client #2 was admitted on December 4, 2025 and discharged on December 23, 2025. A comprehensive treatment plan was developed on December 5, 2025 with no type or frequency identified.
Client #3 was admitted on October 8, 2025 and discharged on December 12, 2025. A comprehensive treatment plan was developed on November 7, 2025 with no type or frequency identified.
Client #4 was admitted on January 29, 2026 and discharged on February 17, 2026. A comprehensive treatment plan was developed on February 10, 2026 with no type or frequency identified.
Client #6 was admitted on February 23, 2026 and discharged on March 10, 2026. A comprehensive treatment plan was developed on February 24, 2026 with no type or frequency identified.
Client #7 was admitted on November 7, 2025 and discharged on January 22, 2026. A comprehensive treatment plan was developed on November 21, 2025 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A comprehensive audit of all active client treatment plans was conducted and updated immediately to include type of services, frequency of services, and evidence of client involvement in development of the plan.
All clinical staff have been re-trained on treatment planning. Weekly audits will be conducted to ensure every current active client's treatment plan includes type and frequency are documented and that client's signatures are present. Clinical Supervisor and Facility Director will be in charge of conducting the weekly audits, the Regional Risk Manager will also be involved in client chart audits for any oversights.
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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 fire drill logs, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to document whether a fire alarm or smoke detector was set off during the time of the drill were submitted and approved by the Department for the February 2, 2024 and February 13, 2025 and September 25, 2025 licensing inspections. Documenting whether a fire alarm or smoke detector was set off during the time of the drill training was again found to be a deficiency in the March 26, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BHA Supervisor and Office Manager, who are responsible for conducting drills were re-educated on proper procedures and documentation requirements. All fire drills conducted in 2026 have been reviewed and correctly marked. BHA Supervisor and Office Manager will continue to be in charge of all upcoming monthly drills and sending them monthly to the Regional Risk Manager who will be the last staff member to review all drills.
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