INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 22-23, 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 of York 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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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on a review of the client census and the employee timesheets for May 2, 2026, through May 7, 2026, the facility failed to employ a sufficient number of support staff to ensure efficient and safe operations of all of the services provided.One of the support staff working third shift is nursing staff and this person is also considered the primary care staff person for the detoxification services. The nurse addresses medical concerns for the clients in detoxification services and residential services. The other support staff working third shift is a Behavioral Health Associate who completes observations on all clients. Both of these staff must also perform admission assessments, body searches as well as searches and inventories of belongings if a new admission arrives during the third shift. On May 2, 2026, the facility had 6 detoxification clients and 39 residential clients. There were two support staff working from 12 am - 6:30 am and 11:30 pm - 12 am.On May 3, 2026, the facility had 7 detoxification clients and 41 residential clients. There were two support staff working from 11:30 pm - 12 am On May 4, 2026, the facility had 5 detoxification clients and 39 residential clients. There were two support staff working from 12 am - 6 am, 6:15 am-7 am, and 11:30 pm - 12 am.On May 5, 2026, the facility had 6 detoxification clients and 40 residential clients. There were two support staff working from 12 am - 6:30 am and 11:30 pm - 12 am.On May 6, 2026, the facility had 7 detoxification clients and 40 residential clients. There were two support staff working from 12 am - 6 am and 11 pm - 12 am.On May 7, 2026, the facility had 7 detoxification clients and 41 residential clients. There were two support staff working from 12 am - 6 am and 11 pm - 12 am.
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Plan of Correction
Facility will schedule a minimum of two BHA's and one nurse nightly to ensure proper staffing to accommodate admissions. The BHA supervisor will be tasked with creating a backup schedule to ensure the facility is staffed in event of a call off. In the event of a call off, there will be no admissions scheduled overnight and the only responsibility of the BHA is client rounding. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on July 22, 2026, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times.Bathroom # 20 has paint chipping off the wall in the shower stall. Bathroom # 64 has a hole in the wall by the mirror and 2 holes in the wall across from the toilet.The first bathroom in A-wing has paint chipping off the walls in the shower stalls. Bedroom # 11 has paint peeling off the wall accross from the door. The bench located in the hallway by nurses ' station has material with multiple stains on the seat.
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Plan of Correction
Stained bench by nursing has been discarded and replaced.
All damaged areas have been repaired by the maintenance supervisor. Moving forward an electronic log has been created for staff to document needed repairs; maintenance will review at a minimum of three times per week and document when repairs are completed. Campus director will review with the maintenance director weekly to ensure all repairs are completed. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on July 22, 2026, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.Bathroom # 20 had soap chips and a medicine cup in the shower.The first bathroom in A-wing had a dirty shoe print on the floor of the first shower and the third shower had a shower curtain that was stained yellow at the bottom.
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Plan of Correction
Dirty shower curtain was discarded.
Campus director met with manager of the cleaning company on August 4th to discuss a plan of correction for her team. Facility will provide additional cleaning tools for the team and research commercial floor scrubbers to be used by maintenance staff.
Leadership rounds implemented two times per week to assess cleanliness of the building. Rounds will be reviewed by director, CEO, and risk and will notify cleaning crew if improvements are needed. |