INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted May 21, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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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 complaint investigation conducted on May 21, 2025, the facility failed to maintain hot water not exceeding 120F.
The basement staff bathroom sink was observed to have hot water measured at 149F.
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Plan of Correction
Water temperature was lowered to 120F for entire facility. Monthly monitoring will be held during Risk and Safety walkthroughs. |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on meal observation and client interviews conducted during a complaint investigation on May 21,2025, the facility failed to keep cold food at or below 40F and hot food at or above 140F. The facility failed to ensure that food prepared offsite and delivered to the facility is maintained in accordance with these temperatures.
The provided hot meals on May 21, 2025, were observed to be sitting out in the breakroom from when they were delivered at noon, until around 3:30 p.m. when Partial Hospitalization Program (PHP) services concluded. On May 21, 2025 the lunch included hot dogs with buns, chicken patty sandwiches, and chips. The dinner, which was stored in large aluminum containers, was baked pasta with melted cheese and marinara sauce along with bread sticks. The aluminum containers covered with aluminum foil, upon delivery, felt warm to the touch in the early afternoon. The food was observed to be sitting out on the table in the breakroom all afternoon without being refrigerated or kept warm. The PHP clients took the containers of food back to their provided housing to heat up for dinner. The food was observed to not be maintained at the appropriate temperature during PHP programming.
There were no food tables or other mechanisms observed in the outpatient facility to keep the hot food hot, or to keep the cold food cold. The food was prepared at the project's inpatient facility and delivered to the outpatient facility. The project's inpatient policy indicates that food should not be left out for more than two hours. The food was observed to be left out for three and half hours.
The provided food service policy covers the project's inpatient facilities' food storage and meal preparation. The policy does not address the outpatient facility having food delivered, served, and stored appropriately prior to it being transported to the provided client housing. At the time of the investigation, the outpatient facility did not have a food service policy.
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Plan of Correction
Outpatient food serving and storage procedures were added to the current White Deer Run food service policy.
VIII. NONRESIDENTIAL FACILITIES WITH CATERED MEALS
A. Facility will maintain enough refrigeration units to keep cold food at or below 40F.
B. Facility will maintain enough food warmers to keep hot food at or above 140F.
C. Facility will maintain enough freezer units to keep frozen food at or below 0F.
Two food tray warmers and an additional refrigerator were purchased to maintain proper food temperature requirements.
Walkthroughs of facility by direct care supervisor to ensure food is stored properly will be completed on a daily basis. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of incident reports and other administrative documentation during a complaint investigation conducted on May 21, 2025, the facility failed to file an unusual incident report involving an event at the facility requiring the presence of police, fire or ambulance personnel.
- On 1/21/2025 facility staff called 911 and an ambulance took a client to York Hospital.
- On 2/11/2025 EMS was called to transport a client to Wellspan hospital.
- On 4/2/2025 a client was removed from the property by York police.
- On 4/6/2025 a client showed up at the facility with a police officer to obtain the client's medications and materials.
- On 4/16/2025 facility staff called 911 and emergency personnel transported a client to crisis services.
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Plan of Correction
Facility gained access to the ERS system. Regional Risk Manager is now uploading all unusual incidents into the system. |