INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on September 25, 2025 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 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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705.28 (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 February, 2025 - August, 2025 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill. The facility does not have a waiver for this regulation.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 2, 2024 and February 13. 2025 licensing inspection.
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Plan of Correction
All smoke detectors are confirmed to be on a wirelessly linked system. The BHA Supervisor will be using the "test" button on the smoke detectors to set off the system during drills. Facility director and Risk Manager will oversee each drill. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from February, 2025 - August, 2025, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit route, the back door.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Every month a different exit will be used during the monthly fire drill. A chart listing all the exits will be marked off and placed in the safety binder to ensure multiple exits are being utilized and practiced throughout the year. The Regional Risk and Quality staff member and the BHA Supervisor will monitor different exits are being used during the monthly fire drill. |
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 for whether or not 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 6, 2024, and February 13, 2025 annual licensing inspections. Whether or not a fire alarm or smoke detector was set off during the time of the drill was again found to be a deficiency in the September 25, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will do monthly fire drills, alternating the different exits. This will be executed by the BHA Supervisor, who will press the "test" button on the wireless linked system in the building. Facility Director and Regional Risk Manager will observe and monitor to ensure all exits are being utilized and proper documentation is being completed. |