INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on September 24-25, 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 Center 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(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 that 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 nine applicable records. Staff #5 was hired as a clinical supervisor on March 16, 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
All relevant staff will review the DDAP 704.6 © Licensure Core Curriculum-Supervisor Training by 11/1/25. Current staff member that was hired as a clinical supervisor without the required previous supervision experience or completing a core curriculum in clinical supervison was placed in a lead therapist role. He is scheduled for the DDAP Clinical Supervision training in Reading on 11/3/25-11/7/25. Agter successful completion of that training, he will be placed back into his clinical supervisior role. The Regional Executive Director of Residential Services will be responsible for implementing this plan. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually in one of eight applicable records. Staff # 34 was hired to the position of counselor on November 30, 2015 and was in this position at the time of review. Staff #34 did not complete at least 25 hours of training throughout the January 1, 2024 through December 31, 2024 training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All relevant staff will review the DDAP 704.11 (f )(2) regulation by 11/1/2025. They will sign off on their understanding of the requirement for yearly 25 clock hour training. The training coordinator will audit training hours for all staff monthly and send an updated training chart to the clinical managers and directors of each location.
During supervision, the clinical manager and/or director will review the monthly clock hours and document on the supervision form that the training hours were discussed.
Once a month, there will be a minimum of 2 hour all staff training at each location during a staff meeting to add to staff training hours for the year.
The clinical managers and directors will be educated by November 1, 2025 on the new training audit process and will be implemented by December 1, 2025. |
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 treatment and rehabilitation plans are reviewed and updated at least every 60 days in two of five applicable records. Client #15 was admitted to the outpatient level of care on June 13, 2025 and was active at the time of review. Client #15 had a treatment plan completed on July 11, 2025. The next treatment plan update was due no later than September 11, 2025; however, the next treatment plan update was not completed until September 19, 2025. Client #19 was admitted to the outpatient level of care on March 17, 2025 and was discharged August 29, 2025. Client #19 had a treatment plan completed on May 15, 2025. The next treatment plan update was due no later than July 15, 2025; however, the next treatment plan update was not completed until July 25, 2025.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. |