INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 16, 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:
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Plan of Correction
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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 residential client interviews and a review of facility grievances, the facility failed to follow its written procedures for the management of treatment/rehabilitation services for clients.
The facility ' s grievance policy notes that client grievances will be responded to " ...within 48hrs " of receipt by the facility.
Client #3 was admitted July 7, 2026, and was still active at the time of the inspection. Client #3 filed a grievance with the facility on July 11, 2026. A review of the filed grievance revealed that the facility had not documented a response to the client as of the date of the onsite complaint investigation, July 16, 2026.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Plan of Correction: The facility's grievance response protocol has been revised to strengthen oversight, accountability, and timely resolution of patient grievances. Effective immediately, all patient grievances will be communicated upon receipt through a designated email distribution group that includes the Chief Executive Officer (CEO), Quality Improvement (QI) Director, Clinical Director, Director of Nursing, and the applicable Department Supervisor. This notification will occur as soon as the grievance is received from the patient.
Within 24 hours of receipt, the grievance will be assigned to the supervisor responsible for the department(s) involved in the grievance. The assignment will be communicated to the senior leadership email group to ensure ongoing leadership awareness and oversight throughout the grievance process.
The assigned supervisor will meet with the patient within 48 hours of assignment to review the concern and initiate the Grievance Response Form. The form will document the following:
- Date the grievance was received
- Date of response
- Patient name and identification number
- Patient treatment unit
- Description of the concern or incident
- Patient's requested or expected resolution
The assigned supervisor will investigate the grievance, collaborate with the patient to address the concern, and implement any necessary corrective actions to achieve resolution. Upon resolution, the supervisor will complete the Grievance Response Form, including a summary of the investigation, findings, actions taken, and outcome. The supervisor will then sign and date the form and submit it via email to the senior leadership distribution group for review and final oversight.
The CEO will maintain a centralized grievance file containing completed grievance documentation for quality improvement activities, ongoing monitoring, and future regulatory survey review.
This revised process ensures timely response, leadership involvement, documentation consistency, and appropriate oversight of all patient grievances.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of residential client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan.
Client #1 was admitted on June 24, 2026, and was still active at the time of the inspection. The treatment plan dated June 27, 2026, indicated one individual session weekly. There was no documentation of the client receiving an individual session during the week of June 28-July 4, 2026.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
On July 22, 2026, the facility implemented an audit tool designed to automatically identify and populate documentation due dates, enhancing the timely completion and monitoring of clinical documentation requirements.
To ensure compliance, supervisors will conduct weekly audits of eight randomly selected client charts per treatment unit. In addition, Clinical Director and Assistant Clinical Director will independently review eight client charts each week. At the end of each week, supervisors will provide the Clinical Directors with the chart numbers reviewed, along with a summary of audit findings and any identified concerns.
Any instances of noncompliance, incomplete documentation, or documentation deficiencies identified through the audit process will be addressed promptly with the responsible staff member. Corrective measures may include coaching, retraining, performance improvement interventions, and disciplinary action when warranted.
Clinical leadership will monitor audit results on an ongoing basis to identify trends, implement corrective actions, and ensure accountability. Routine auditing and oversight will continue to promote sustained compliance, improve documentation practices, and support adherence to all applicable regulatory and organizational requirements.
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