INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 7-8, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 3W6N6701 The Gatehouse was found not to 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.
|
Plan of Correction
|
§ 717.17(c) LICENSURE Personnel Management
§ 717.17. Personnel management.
(c) The licensee shall maintain a personnel record for the house manager and each staff person and volunteer, which must include:
(1) Application or resume.
(2) A Pennsylvania State Police criminal history record check.
(3) Disciplinary actions.
(4) A written job description for each drug and alcohol recovery house position.
(5) Documentation of training.
|
Observations
Based on a review of staff # 4's personnel record, the facility failed to provide documentation of a complete personnel record to include: (1) Application or resume. (2) A Pennsylvania State Police criminal history record check. (3) Disciplinary actions. (4) A written job description for each drug and alcohol recovery house position. (5) Documentation of training. Staff #4 was hired as lead resident on January 5, 2026 and was still in this position at the time of the inspection. There was no documentation provided of a complete personnel record to include an application or resume and Pennsylvania State Police criminal history record check. These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
In an effort to address citation 717.17 (c), the following will be implemented:
Beginning on 4/16/26, all new "Lead Residents" will be categorized as volunteers to their position and the following will apply:
Resume submission, criminal history check, disciplinary actions as needed, signed job description, and documentation of trainings.
The GTL Coordinator will be responsible to ensure that the abovementioned is completed for all new "Lead Residents".
The Program Director will oversee this action step and ensure its completion during monthly supervision.
|
§ 717.22(b)(4) 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:
(4) Consent to residency.
|
Observations
Based on one of six resident records reviewed, the facility failed to provide a consent to residency which must be signed by the resident within 24 hours.Resident #1 was admitted on September 19, 2025, and was still active at the time of the inspection. There was not a consent to residency provided in the resident record.These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
In an effort to address citation 717.22 (b) (4), the following will be implemented:
Beginning on 4/16/26 the GTL Coordinator will ensure that all new residents review and sign a copy of the "Consent to Residency" within 24 hours of admission.
The Program Director will monitor this action step during monthly supervision.
|
§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
|
Observations
Based on three of four discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.Resident # 3 was admitted on February 4, 2026, and discharged March 24, 2026. There was no documentation of an end to residency in the resident record.Resident # 4 was admitted on December 10, 2025, and discharged January 12, 2026. There was no documentation of an end to residency in the resident record.Resident # 6 was admitted on November 13, 2025, and discharged January 5, 2026. There was no documentation of an end to residency in the resident record.These findings were reviewed with the recovery house staff during the licensing process
|
Plan of Correction
In an effort to address citation 717.23 the following will be implemented:
Beginning on 4/16/2026, the GTL Coordinator will ensure that a notification to end residency with the stated reason, is given to the resident no less than 24 hours of the intended date to vacate the recovery house.
Residents will be permitted to submit an appeal of the decision to end residency within the 24 hour time frame.
The Program Director will monitor this action step during monthly supervision with the GTL Coordinator.
|