INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on February 19, 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 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 fire drill logs from February 2024 through January 2025, the facility failed to maintain a written fire drill record including the time of the drill. The June and October, 2024 logs did not indicate the time of the drills.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will review all fire drill logs to ensure they are complete and accurate. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from February 2024 through January 2025, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was only completed on December 20, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director applied for a waiver to conduct fire drills aside from the county conducted fire drills. This will allow for all shifts, random days and times to be encompassed for fire drills. Waiver was applied for on 2/27/25.
Should the exception not be granted, Facility director will work with the county to have the county conduct drills on all shifts, varying days and times. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of fire drill logs from February, 2024 through January, 2025, the facility failed to conduct fire drill on all shifts. No drills were completed on the second shift.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director applied for a waiver to conduct fire drills aside from the county conducted fire drills. This will allow for all shifts, random days and times to be encompassed for fire drills. Waiver was applied for on 2/27/25.
Should the exception not be granted, Facility director will work with the county to have the county conduct drills on all shifts, varying days and times. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of detox client records, the facility failed to provide a complete client record, which is to include follow up within the guidelines established by the facility's policy and procedure manual in two out of five applicable records reviewed. The policy states that follow up shall occur within 7 days if the client has an appointment or 30 days with no appointment.
Client #12 was admitted on September 4, 2024 and was discharged on September 6, 2024. No follow up was documented.
Client #13 was admitted on August 23, 2024 and was discharged on August 29, 2024. No follow up was documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 7, 2024 licensing inspection.
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Plan of Correction
Facility Director will audit all discharge charts to ensure follow up form is in the chart. Audits will be done on a regular basis, every Monday, Wednesday, and Friday, to capture all discharges with the follow up form included in the chart. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of inpatient client records, the facility failed to document treatment plan updates within the guidelines established by the facility's policy and procedure manual in two out of four applicable records reviewed. The facility's policy and procedure manual states that updates must be completed every 15 days.
Client #1 was admitted on January 22, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 23, 2025 and an update was due no later than February 7, 2025; however, it was not completed until February 12, 2025.
Client #6 was admitted on December 10, 2024 and discharged on January 16, 2025. A comprehensive treatment plan was completed on December 12, 2024 and an update was due no later than December 27, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will audit all charts on a weekly basis. Facility Director will inform clinical staff of upcoming treatment plan updates that are due at the weekly team meeting. This will ensure staff have enough time to complete the treatment plan updates. |