INITIAL COMMENTS
|
This report is a result of an on-site unusual incident investigation conducted on June 25, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, 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 investigation:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the Patient Bed Checks policy, and the Bed Check logs, the facility failed to follow its written procedures for the management of treatment and rehabilitation services for clients.Per the Patient Bed Checks policy, patients housed in the medical building will be required to have hourly bed checks. Medical/Clinical staff will check each patient room once an hour on each shift. Medical/Clinical staff will document bed check on bed check form and will be kept in the nurse ' s station. Per the Bed Check log dated 6/22/26, there was no documentation of observations being completed at 4:00 am or 3:00 pm.
|
Plan of Correction
Charge nurse for each shift is assigned to distribute an assignment sheet that outlines the bed check role. Each hourly bed check will be assigned to a specific nurse that will be responsible to complete that task. Charge nurse will monitor that hourly bed checks are occurring by the assigned staff and will reassign in extenuating circumstances to ensure bed checks are occurring.
COO/DON and ADON will review bed check form daily for compliance. Target compliance 100%. |