INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 19, 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a review of the facility's physical plant, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
DDAP staff observed an HVAC ceiling register obstructed with tissues and paper towels in Room #2. Additionally, DDAP staff observed an HVAC floor register obstructed with tissues and paper towels in Room #6.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility leadership will incorporate room checks with routine rounding to ensure vents are clear of obstruction. If the vents are found to be stuffed, material will be removed immediately. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain living room or lounge furnishings in a state of good repair.
DDAP staff observed a damaged couch in a patient lounge area near the entrance to the facility's outside courtyard.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Couch was repaired by maintenance on 08/19/2025. Additionally, facility will replace the worn furniture in September 2025 |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to provide 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: progress notes.
Client #3 was admitted on July 31, 2025, and was still active at the time of the inspection. A review of the client record indicated a missing progress note for an individual treatment session that occurred during the week of August 10-16, 2025.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Lead counselor will audit 5 charts weekly for all components including completion of weekly progress note. Supervision will be completed with staff members immediately if documentation is missing and documented. |