INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on September 16, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation - East Liberty 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of staff records, the facility failed to ensure clinical supervisors meet qualifications in one of three applicable records.
Staff # 3 was hired as a clinical supervisor on August 4, 2025 and was in this position at the time of review. Staff #3 does not possess a qualifying degree or certification for the position of clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Staff #3 has been removed from the position of Clinical Supervisor and reassigned to a role consistent with their current qualifications. The facility has designated an appropriately credentialed and qualified Clinical Supervisor to oversee all clinical staff and operations in compliance with 28 Pa. Code § 704.6. The Regional Executive Director will be responsible for training all hiring staff on the qualifications for the Clinical Supervisor position as well as verifying compliance with hiring moving forward. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of staff records, the facility failed to ensure clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision in one of three applicable records.
Staff #6 was hired as a clinical supervisor on February 17, 2025 and was in this position at the time of review. Staff #6 had no record of previous supervision experience in clinical services, as well as no record of completing a core curriculum in clinical supervision as of the time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff # 5 completed the DDAP Clinical Supervisor Foundation Training on 10/7/2025 and the DDAP approved PESI Clinical Supervisor Training on October 12, 2025 to meet the requirments for qualifications of a clinical supervisor. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 complete comprehensive treatment plans within the time frame listed in the facility ' s policy and procedures in five of seven applicable records.
Prior to July 21, 2025, the facility ' s policy and procedure stated that comprehensive treatment plans were to be completed within three visits for the outpatient level of care. Effective July 21, 2025 the facility ' s policy and procedure stated that a comprehensive treatment plan was due within 30 days of admission for the outpatient level of care.
Client #1 was admitted to the outpatient level of care on April 14, 2025 and was active at the time of review. Client #1 ' s comprehensive treatment plan was due to be completed on April 16, 2025; however, the comprehensive treatment plan was not completed until May 20, 2025.
Client #3 was admitted to the outpatient level of care on April 1, 2025 and was active at the time of review. Client #3 ' s comprehensive treatment plan was due to be completed on April 3, 2025; however, the comprehensive treatment plan was not completed until May 13, 2025.
Client #4 was admitted to the outpatient level of care on May 19, 2025 and was discharged August 14, 2025. Client #4 ' s comprehensive treatment plan was due to be completed on May 20, 2025; however, the comprehensive treatment plan was not completed until June 14, 2025.
Client #6 was admitted to the outpatient level of care on February 17, 2025 and was discharged August 1, 2025. Client #6 ' s comprehensive treatment plan was due to be completed on February 20, 2025; however, the comprehensive treatment plan was not completed until March 4, 2025.
Client #7 was admitted to the outpatient level of care on December 2, 2024 and was discharged February 20, 2025. Client #7 ' s comprehensive treatment plan was due to be completed on December 5, 2024; however, the comprehensive treatment plan was not completed until December 29, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion and timeline for the comprehensive treatment plans by October 31, 2025. The Program Manager will be responsible for verifying timely completion of the comprehensive treatment plans by completing random chart supervision in 10% of the active charts monthly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every 60 days in four of seven applicable records.
Client # 1 was admitted to the outpatient level of care on April 14, 2025 and was active at the time of review. Client #1 had a treatment plan completed on May 20, 2025. The next treatment plan update was due no later than July 20, 2025; however, the next treatment plan update was not completed until August 13, 2025.
Client #2 was admitted to the outpatient level of care on March 26, 2025 and was active at the time of review. Client #2 had a treatment plan completed on April 14, 2025. The next treatment plan update was due no later than June 14, 2025; however, the next treatment plan update was not completed until June 23, 2025.
Client #3 was admitted to the outpatient level of care on April 1, 2025 and was active at the time of review. Client #3 had a treatment plan completed on May 13, 2025. The next treatment plan update was due no later than July 13, 2025; however, the next treatment plan update was not completed until August 13, 2025.
Client #5 was admitted to the outpatient level of care on February 19, 2025 and was discharged June 2, 2025. Client #5 had a treatment plan completed on March 21, 2025. The next treatment plan update was due no later than May 21, 2025; however, no further treatment plan updates wre completed prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion and timeline for treatment plan reviews by October 31, 2025. The Program Manager will be responsible for verifying timely completion of the review treatment plans by completing random chart supervision in 10% of the active charts monthly. |