INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on September 17-18, 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 Greensburg 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 #5 was hired as a clinical supervisor on February 17, 2025 and was in this position at the time of review. Staff #5 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 requirements 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 three 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 #4 was admitted to the outpatient level of care on January 13, 2025 and was discharged July 21, 2025. Client #4 ' s comprehensive treatment plan was due to be completed on January 15, 2025; however, the comprehensive treatment plan was not completed until February 17, 2025.
Client #6 was admitted to the outpatient level of care on February 12, 2025 and was discharged June 19, 2025. Client #6 ' s comprehensive treatment plan was due to be completed on February 17, 2025; however, the comprehensive treatment plan was not completed until March 10, 2025.
Client #7 was admitted to the outpatient level of care on February 3, 2025 and was discharged July 17, 2025. Client #7 ' s comprehensive treatment plan was due to be completed on February 6, 2025; however, the comprehensive treatment plan was not completed until February 10, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 29, 2024 annual licensing renewal inspection.
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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(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to ensure that individual treatment plans include type and frequency of treatment and rehabilitation services in three of seven applicable records.
Client #1 was admitted to the outpatient level of care on February 10, 2025 and was active at the time of review. Client #1 ' s treatment plan dated February 26, 2025 did not contain a type and frequency of treatment and rehabilitation services.
Client #3 was admitted to the outpatient level of care on May 1, 2025 and was active at the time of review. Client #3 ' s treatment plan dated May 29, 2025 did not contain a type and frequency of treatment and rehabilitation services.
Client #6 was admitted to the outpatient level of care on February 12, 2025 and was discharged June 19, 2025. Client #6 ' s treatment plan dated March 10, 2025 did not contain a type and frequency of treatment and rehabilitation services.
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 of the treatment plan to include type and frequency of treatment by October 31, 2025. The Program Manager will be responsible for verifying time and frequency is included in treatment plans by completing random chart supervision in 10% of the active charts monthly. |