INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 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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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 #8 was hired as a driver on November 10, 2022 and was still in the position at the time of the inspection. Her training was due no later than November 10, 2024; however, none was completed.
Employee #9 was hired as maintenance on November 28, 2022 and was still in the position at the time of the inspection. His training was due no later than November 28, 2024; however, none was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. HR Director is responsible for ensuring all staff are in compliance with all trainings.
2. HRD is working with DDAP to provide an onsite trainer to complete the training with all staff.
3. Trainings will be offered at least twice annually.
4. Completion certificates will be provided to HR and file in employee files.
5. An employee checklist will be created by HR with mandatory trainings to be audited quarterly for compliance. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Exception request submitted to DDAP to allow cameras use in common areas that are utilized for groups. Cameras do not record audio and are only accessed by supervisors to investigate safety concerns.
Cameras will be removed. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide an operable soap dispenser in each bathroom. There was no soap in the detox unit bathroom.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Safety walk throughs to be conducted by risk manager and BHA supervisor monthly to check patient care areas for concerns. These will be documented and properly addressed.
2. Facility will be switching cleaning vendors mid-March due to continued complaints.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store al food items off the floor. There was a box of potatoes on the floor in the refrigerator.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
BHA supervisor and risk manager to complete scheduled walk throughs to identify client health and safety concerns. |
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 whether the fire alarm or smoke detector was operative. The April, 2024 log did not indicate if the fire alarm or smoke detector was operative. A verbal announcement was given.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
Risk manager and facility director to check safety binder monthly to ensure all scheduled drills are being conducted correctly. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of residential client records, the facility failed to document a comprehensive treatment plan 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 the comprehensive treatment plan must be completed within 72 hours following admission.
Client #8 was admitted on January 21, 2025 and was still active at the time of the inspection. A treatment plan was due no later than January 24, 2025; however, it was not completed until February 6, 2025
Client #9 was admitted on January 3, 2025 and was still active at the time of the inspection. A treatment plan was due no later than January 6, 2025 and was not completed until January 7, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Lead counselor will re-educate all counseling staff on treatment plan completion, timeframes and expectation. This will be done by 03/01/2025.
2. The lead counselor will conduct 5 chart audits weekly to ensure treatment plans are completely timely. |
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 residential client records, the facility failed to document treatment plan updates within the guidelines established by the facility's policy and procedure manual in four out of five applicable records reviewed. The manual states that updates will be completed every 14 days,
Client #9 was admitted on January 3, 2025 and was still active at the time of the inspection. A treatment plan update was completed on January 27, 2025 and the next update was due no later than February 10, 2025; however, none was completed.
Client #10 was admitted on January 6, 2025 and was still active at the time of the inspection. A treatment plan was completed on January 8, 2025 and an update was due no later than January 22, 2025; however, none was completed.
Client #11 was admitted on January 15, 2025 and was still active at the time of the inspection. A treatment plan was completed on January 16, 2025 and an update was due no later than January 30, 2025; however, it was not completed until January 31, 2025.
Client #12 was admitted on November 18, 2024 and was discharged on December 16, 2024. A treatment plan was completed on November 21, 2024 and the next update was due no later than December 5, 2024; however, it was not completed until December 12, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2, 2024 licensing inspection.
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Plan of Correction
1. Lead Counselor as part of the overall treatment plan re-education with all counselors will include the timeframe on treatment plan updates.
2. Lead counselor will complete 5 chart audits weekly to ensure treatment plan updates are being completely timely. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include case consultation within 72 hours of admission according to the facility's policy and procedures manual in five out of seven records reviewed.
Client # 8 was admitted on January 21, 2025 and was still active at the time of the inspection. No case consultation was completed.
Client # 10 was admitted on January 6, 2025 and was still active at the time of the inspection. No case consultation was completed.
Client # 11 was admitted on January 15, 2025 and was still active at the time of the inspection. No case consultation was completed.
Client # 12 was admitted on November 18, 2024 and was still discharged on December 16, 2024. No case consultation was completed.
Clientt # 13 was admitted on November 18, 2024 and was discharged on December 16, 2024. No case consultation was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Lead Counselor will complete re-education/training for all counseling staff on the completion of the case consultation within 72 hours of admission. This will be completed by 03/01/2025.
2. Lead counselor to complete 5 weekly chart audits to ensure case consultations are being completed. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of residential client records, the facility failed to provide a complete patient record, which is to include a discharge summary in one out of three records reviewed.
Client #13 was admitted on November 18, 2024 and was discharged on November 20, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Discharge summary re-education will be had by all counseling staff by the Lead Counselor by 03/01/2025.
2. Lead counselor will complete 5 chart audits weekly (including closed records) to ensure discharge summaries are being completed. |
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 residential 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 three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed at 7 days if they have an appointment or 30 days if no appointment following discharge.
Patient #13 was admitted on November 18, 2024 and was discharged on November 20, 2024.
Patient #13 was admitted on November 18, 2024 and was discharged on November 20, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. All counselors will be educated on the new after care follow up form.
2. Facility Director will determine who will make follow up calls within the timeframes.
3. Lead counselor will complete 5 chart audits weekly (including discharged records) to ensure follow ups are being completed. |