INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 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 #6 was hired as BHT Supervisor on February 5, 2024 and was still employed at the time of the inspection. Her training was due no later than February 5, 2026; however, none was completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #6 is currently out on medical leave. Upon her return to work, she will have one month to schedule and attend HIV/Aids and TB/STD training. This will be completed no later than 6/1/26.
To prevent this from occurring in the future, Facility Director will review employee training plans with Managers at Manager Meeting to ensure Managers are having their direct reports complete their trainings in a timely fashion |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure an employee received the required training in the use of the fire extinguishers upon employment.
Employee #4 was hired on August 12, 2025 for the position of counselor and was still employed at the time of the inspection. The training was due no later than August 19, 2025. However, it was not completed until November 13, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 is no longer employed with White Deer Run. To ensure this does not occur again, all new hire training including fire extinguishers and emergency training will be done on first day of hire for all employees. Once the training is completed, it will be sent to HR to verify staff members are trained appropriately. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure an employee received the required training to perform assigned tasks during emergencies.
Employee #4 was hired on August 12, 2025 for the position of counselor and was still employed at the time of the inspection. The training was due no later than August 19, 2025. However, it was not completed until November 13, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 is no longer employed with White Deer Run. To ensure this does not occur again, all new hire training including fire extinguishers and emergency training will be done on first day of hire for all employees. Once the training is completed, it will be sent to HR to verify staff members are trained appropriately. |
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 the February, 2025 through February, 2026 fire drill logs during the inspection, the facility failed to document the exit route used during the fire drill. There is no documentation for the February, 2025 and August, 2025 drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All fire drills will be written out by one staff member with a sign off from Facility Director to ensure all parts of the fire drill paperwork are complete and thorough. |
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 notify the emergency contact of the client leaving the facility against medical advice in two out of two client records.
Client #1 was admitted to the inpatient level of care on November 10, 2025 and was discharged on November 12, 2025.
Client #12 was admitted to the detox level of care on November 1, 2025 and was discharged on November 18, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A chart note will be added to our EMR to ensure documentation of call to emergency contact is in the chart. The note will include the client name, the fact that the client left against advice, and it will have a place to document the emergency contact being notified. This will be placed into the EMR on 3/25/26.
The staff member who is filling out the incident report will also fill out the AMA note and will be responsible for attempting to contact the EMC.
Facility Director will conduct chart audits daily to ensure EMC calls are being made. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of inpatient client records, the facility failed to document follow-up information within guidelines established by the facility's policy and procedures manual in two out of six applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed within 7 days following a referral for an appointment or 30 days following discharge if no appointment.
Client #8 was admitted on January 13, 2026 and was discharged on February 17, 2026 with an appointment on February 19, 2026. A follow-up was due no later than February 26, 2026. However, it was not completed until March 2, 2026.
Client #12 was admitted on November 11, 2025 and was discharged on November 18, 2025. A follow-up was due no later than November 25, 2025. However, none was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions coordinator will run a discharge report daily. She will fill out a follow up form for any that are missing. Follow up calls will be completed once per week to ensure all follow ups are done in a timely manner. Facility Director will conduct chart audits weekly to ensure the follow up forms are completed and uploaded into their EMR. |