INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 31, 2026 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure a clinical supervisor completed a core curriculum in clinical supervision within a timely fashion.Employee #5 was promoted to a clinical supervisor on September 28, 2025 and was still in that position at the time of the inspection. She did not complete the core curriculum at the time of the inspection.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #5 was promoted to the position of Clinical Supervisor on September 28, 2025. Prior to the time of the licensing inspection, the facility had taken steps to ensure compliance with the training requirement. Employee #5 was registered on February 23, 2026, to attend the Department of Drug and Alcohol Programs (DDAP) approved Five-Day Clinical Supervisor Training, scheduled for June 8?12, 2026. This registration occurred prior to the inspection, demonstrating the facility's awareness of the regulatory requirement and its commitment to ensuring the employee completes the mandated core curriculum.
QI Department will monitor staff training requirements and alert Clinical team monthly of whether staff are coming due for required training. Clinical director will ensure staff are registered for their required trainings before their due dates.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of inpatient records, the facility failed to verify the individual's identity, including name, address, date of birth, and other identifying information.Patient #6 was admitted to the facility on February 5, 2026 and discharged on February 6, 2026. This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
During admission screening, admission staff will ask whether patient has photo identification they can bring with them into treatment.
During the intake process; intake staff will ask for photo identification and make a copy of the photo identification for the chart.
1. An ID verification form will now be included in all partial packs for clients arriving when Intake is not staffed.
2. Security, and safety staff will be educated on the importance of obtaining ID , if client arrives outside of Intake hours.
3. Every effort will be made to complete partial Intakes during the 1st 24 hours of a client's arrival at the facility.
In the event that a patient arrives after intake hours or an emergency prevents entire completion of intake packet, staff will work with patient to get paper documents signed.
1. Initial ROI's, complete a verification of ID form to verify patients' DOB, name, address and other identifiers.
2. Intake staff will scan the partial packet into the electronic medical record and keep the paperwork for 10 days.
3. EMR will be updated when Intake is complete
4. Intake supervisor will check new admits daily for accuracy of documents and completeness of intake paperwork.
This is how WDR will make sure a client photo is taken
1. Both 3rd shift supervisors have been trained on how to obtain a photo of the client for the HCS chart, while completing a partial intake pack.
2. All clients will be photographed during the FINAL steps of their complete intake
If verification is unable to occur the patient will not be able to participate in methadone/buprenorphine protocol to detox from their drug of choice.
Intake supervisor will review all admissions to ensure that identification or verification of identification has occurred.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of inpatient records, the facility failed to maintain on site a photograph of each patient which includes the patient's name and birth date.Patient #6 was admitted to the facility on February 5, 2026 and discharged on February 6, 2026. This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
During admission screening, staff will ask whether patient has photo identification they can bring with them into treatment.
During the intake process staff will ask for photo identification and make a copy of the photo identification for the chart.
1. An ID verification form will now be included in all partial packs for clients arriving when Intake is not staffed.
2. Security, and safety staff will be educated on the importance of obtaining ID , if client arrives outside of Intake hours.
3. Every effort will be made to complete partial Intakes during the 1st 24 hours of a client's arrival at the facility.
In the event that a patient arrives after intake hours or an emergency prevents entire completion of intake packet, staff will work with patient to get paper documents signed.
1. Initial ROI's, complete a verification of ID form to verify patients' DOB, name, address and other identifiers.
2. Intake staff will scan the partial packet into the electronic medical record and keep the paperwork for 10 days.
3. EMR will be updated when Intake is complete
4. Intake supervisor will check new admits daily for accuracy of documents and completeness of intake paperwork.
This is how WDR will make sure a client photo is taken
1. Both 3rd shift supervisors have been trained on how to obtain a photo of the client for the HCS chart, while completing a partial intake pack.
2. All clients will be photographed during the FINAL steps of their complete intake
If verification is unable to occur the patient will not be able to participate in methadone/buprenorphine protocol to detox from their drug of choice.
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