INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28-29, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 3W6N6701 The Gatehouse was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
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Plan of Correction
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? 717.22(b) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(1) Disclosure to the resident of criteria for beginning and ending residency.
(2) Resident orientation to the drug and alcohol recovery house which must include all of the following:
(i) Drug and alcohol recovery house rules, including a method to record residents ' expected return time to the drug and alcohol recovery house.
(ii) Fee schedule including any lease agreement.
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
(iv) Financial policies and procedures.
(v) The location of posted emergency procedures and contact information for the house manager and the Department.
(vi) Medication control and self-administration policies.
(3) Basic personal data including:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker and other medical conditions that the resident chooses to have in the house record.
(v) Drug and alcohol history.
(vi) Medical contact information.
(vii) Emergency contact.
(4) Consent to residency.
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
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Observations
Based on three of seven resident records reviewed, the facility failed to provide documentation, signed by the resident within 24 hours of arrival, The resident ' s basic personal data is to include:
(i)Name
(ii)Birth Date
(iii)Demographic information
(iv)Medical Information
(v)Drug and alcohol history
(vi)Medical contact information
(vii)Emergency contact
Resident #1 was admitted on February 9, 2025, and is an active resident. The required personal data was not in the resident record.
Resident #2 was admitted on July 16, 2024, and is an active resident. The required personal data was not in the resident record.
Resident #4 was admitted on November 4, 2024, and was discharged January 22, 2025. The required personal data was not in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In an effort to address citation 717.22(b)(3)(i), the following will be implemented:
Beginning on 6/2/2025, the House Manager will train all GateHouse Transitional Living staff on how to complete the basic personal data for each new resident to include the following; name, birth date, demographic information, medical information, drug and alcohol history, medical contact information and emergency contact within 24 hours of the resident's arrival. The residents basic personal data will be filed in the resident's chart.
The House Manager will monitor the progress of this plan during monthly supervision.
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§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
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Observations
Based two of four discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident #4 was admitted on November 4, 2024, and was discharged January 22, 2025. There was not a notification to the emergency contact provided in the resident record.
Resident #5 was admitted on November 4, 2024, and discharged April 2, 2025. There was not a notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In an effort to address citation 717.27, the following will be implemented:
Beginning on 6/2/2025, the House Manager will ensure that all GateHouse Transitional Living staff are trained on the requirement to notify the residents emergency contact if and when the resident decides to end their residency, does not return to the residence, GTL ends the residency, or in the case of a medical emergency or death, within 12 hours of the event. The contact will be documented in the residents record.
The House Manager will monitor this plan monthly while providing supervision to the GTL staff.
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