INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on February 25-26, 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, Inc. 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 #31 was hired as a dietary aide on August 1, 2022. His trainings were due no later than August 1, 2024; however, none was completed. Employee #32 was hired as a dietary aide on September 26, 2022. Her training was due no later than September 26, 2024; however, her TB/STD training was not completed as of the time of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Infection Control Nurse and QI Coordinator will track employee's communicable disease training and alert staff who is still in need of trainings prior to the trainings being offered to ensure staff attendance and compliance with regulation. Tracking sheet will be sent to facility managers/leadership monthly to ensure they are aware who is still in need of training.
Infection control nurse and Human resource department has added TB/STD training to new hire orientation. All new staff are required to attend new hire orientation. Facility leadership will register at least 5 staff in addition to the new hires in attendance to attend one and/or both of these trainings until all staff hired prior to 1/1/25 have received the trainings.
Failure to attend training within required timeframe will result in disciplinary action.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential 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 physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. Building 25, room 1's hot water temperature was recorded at 142.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility corrected the water temperature the day of the inspection by adjusting the water heaters and checking the water temperature until it was 120 degrees.
The facility management staff will conduct monthly leadership rounds and maintenance department will conduct maintenance rounds where water temperature checks will be noted to ensure that hot water temperatures will not exceed 120 degrees.
If/when it is noted that the temperature is above 120 degrees, staff conducting the leadership rounds and/or maintenance rounds will notify maintenance team to have the temperature adjusted through the water heater and testing the temperature until correct, immediately.
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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 one employee received the required training in the use of fire extinguishers in the required seven days. Employee #7 was hired on June 10, 2024 for the position of counselor and was still employed at the time of the inspection. The training was completed on June 27, 2024.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
New hired staff will be trained on fire safety; fire extinguishers, fire drills and their roles/responsibilities during emergencies within 7 days of hire through their job specific orientation training and/or new hire; path to purpose training.
Human resource department will track to ensure that job specific orientation training and/or new hire orientation training has occurred within 7 days of hire.
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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 one employee received the required training to perform assigned tasks during emergencies in the required seven days. Employee #7 was hired on June 10, 2024 for the position of counselor and was still employed at the time of the inspection. The training was completed on June 27, 2024.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
New hired staff will be trained on fire safety; fire extinguishers, fire drills and their roles/responsibilities during emergencies within 7 days of hire through their job specific orientation training and/or new hire; path to purpose training.
Human resource department will track to ensure that job specific orientation training and/or new hire orientation training has occurred within 7 days of hire.
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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 detox patient records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice in three out of three applicable records. Patient #1 was admitted on August 14, 2024 and discharged on August 18, 2024.Patient #2 was admitted on August 14, 2024 and discharged on August 18, 2024.Patient #3 was admitted on August 13, 2024 and discharged on August 18, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisors will train all new counselors and re-train all counselors on AMA procedures that include making calls to emergency contacts if a patient leaves AMA and documenting the contact in medical record.
Clinical director will meet with 2nd/3rd shift supervisors to review the AMA procedures that include making calls to emergency contacts if a patient leaves AMA and documenting the contact in medical record.
Clinical supervisors will review AMA discharge charts prior to end of their shift to ensure that emergency contact calls were made and documented in the chart.
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