INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 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.- Lancaster 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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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 two employees received the required training in the use of the fire extinguishers upon employment.
Employee #2 was hired on December 2, 2024 for the position of facility director and was still employed at the time of the inspection. He did not have the training until December 12, 2024.
Employee #4 was hired on November 18, 2024 for the position of counselor and was still employed at the time of the inspection. She did not have the training until December 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All employees will receive fire extinguisher training during new hire orientation or on day 1 of employment. When done at the facility level, a manager will review with a team member on 1st day and provide documentation to HR. |
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 during the months of December 2024 and January 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The BHA Supervisor will be re-educated on the regulatory requirements of fire drills and how to properly fill out the form by the Facility Director. This will be done by 03/01/2025.
All fire drill logs will be submitted to Facility Director for review before being finalized to ensure compliance. |
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 client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 7 days following admission.
Client #8 was admitted on January 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 13, 2025; however, it was not completed until January 16, 2025.
Client #10 was admitted on August 27, 2024 and was discharged on September 6, 2024. A comprehensive treatment plan was due no later than September 4, 2024; however, none was completed.
Client #11 was admitted on October 31, 2024 and discharged on January 9, 2025. A comprehensive treatment plan was due no later than November 6, 2024; however, it was not completed until December 11, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Weekly treatment team meeting will include a review of all scheduled treatment plans and a confirmation of completion.
New Work Flow chart is being developed for use by counselors.
Checklist will be reviewed during weekly supervision with counselors and upon completion of client's stay to ensure compliance.
Work with IT Department to correct issue involving the date changing on treatment plans when an update is completed.
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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 client records, the facility failed to provide a complete client record, which is to include a discharge summary in three out of five records reviewed.
Client #10 was admitted on August 27, 2024 and was discharged on September 6, 2024.
Client #13 was admitted on November 4, 2024 and was discharged on January 24, 2025.
Client #14 was admitted on November 30, 2024 and was discharged on December 4, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New Work Flow chart is being developed for use by counselor that will include the completion of the discharge summary.
A clinical checklist will be reviewed during supervision and upon completion of client's stay.
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