INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 21, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Gate House for Men 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. Employee #6 was hired as Recovery Specialist on August 28, 2022. His training was due no later than August 28, 2024; however, none was completed. This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 704.11 (c) (1), the following will be implemented:
Beginning on 1/28/2026, the Residential Program Supervisor will ensure that all recovery support staff complete 6 hours of HIV training, and at least 4 hours of TB/STD training within two years of employment.
In addition, employee #6 will complete these trainings by 2/6/2026.
The Program Director will monitor the progress of this action step during monthly supervision with the Residential Program Supervisor. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to provide hot water in a bathroom. The bathroom on the third floor had no hot water.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 705.6 (3), the following will be implemented:
On 1/28/2026, the maintenance staff will ensure that all the bathrooms through out the facility have running hot water, not to proceed 120 degrees.
In addition, the Residential Program Supervisor will ensure the running of the hot water during a weekly check. In the event that an issue arises, the maintenance department will be notified.
The Program Director will monitor the outcome of this action step during monthly supervision with the Residential Program Supervisor. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.Client #5 was admitted on August 4, 2025 and discharged on December 29, 2025. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
In an effort to address citation 709.33 (a), the following will be implemented:
Beginning on 1/28/2026, the Clinical Supervisor will ensure that each clinician is completing a "Notice of Termination" along with the reason in the event that the client leaves treatment prematurely, or is therapeutically discharged.
The Clinical Supervisor will monitor the completion of this form when completing monthly chart reviews. |