INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 25, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, White Deer Run of York, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document progress on short and long term goals for treatment as formulated by both staff and clients. Client #1 was admitted on July 21, 2025, and was discharged on August 20, 2025. A treatment plan was completed on July 24, 2025. The treatment plan noted " client will work with counselor one on one to identify medication free ways of reducing anxiety and depression. " A treatment plan update was completed August 5, 2025. There was no documentation on the updated treatment plan or in the client record to verify that this goal was addressed. This finding was reviewed with the facility staff during the complaint investigation.
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Plan of Correction
Clinical supervisor will provide staff training to address all treatment plan goals in weekly notes and complete routine chart audits to check progress. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within timeframes noted in facility policies. It is the facility ' s policy to update treatment plans every fourteen days.Client #1 was admitted on July 21, 2025, and was discharged on August 20, 2025. A treatment plan was completed on August 5, 2025, and the next update was due no later than August 19, 2025; however, there were no further updates documented in the client record. This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Clinical supervisor will complete training with staff on all applicable treatment plan updates and complete routine chart audits to check progress. |