INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gate House- Marietta 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employee #7 was hired as a Recovery Specialist on October 31, 2022 and was still in the position at the time of the inspection. Her training was due no later than October 31, 2024; however, it was not completed until December 23, 2025.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the December 19, 2024 licensing inspection.
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Plan of Correction
In an effort to address citation 704.11 (c) (1), the following will be implemented:
Beginning 2/5/2026, the Residential Program Supervisor, or the Clinical Supervisor will ensure that all new hires complete the required HIV/STD and TB trainings within the allotted time frames. 2 years for recovery support staff, and 1 year for counselors and counselor assistants.
The Program Director will monitor the outcome of this plan during monthly supervisions with both the Residential Program Supervisor, and the Clinical Supervisor. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to maintain the refrigerator temperature according to the regulation. The facility's kitchen refrigerator temperature was measured at 50 degrees at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
In an effort to address citation 705.7 (b) (5), the following will be implemented:
Beginning on 2/5/2026, the Residential Program Supervisor will check the temperatures on all the refrigerators on a weekly basis to ensure it is set at 40F. If the temperature reading is over the 40F, the Residential Supervisor will adjust the temperature to meet the standard. If the temperature does not meet the standard, a request will be submitted to the maintenance department to fix the refrigerator or replace it.
The Program Director will monitor the results on a monthly basis during supervision with the Residential Program Supervisor. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure employees received the required training to perform assigned tasks during emergencies.
Employee #6 was hired on October 7, 2025 for the position of counselor and was still employed at the time of the inspection. The training was due no later than October 14, 2025; however, it was not completed until December 29, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (d) (3), the following will be implemented:
Beginning on 2/5/2026, all new hires will complete the "Emergency Procedures" training, that includes fire safety procedures during the orientation period with the HR Generalist. The orientation period begins on the first day of employment and typically last for 3 to 4 days. This training is currently on our new electronic system, Paychex.
The Director of Compliance will monitor the outcome of this plan on a monthly basis. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #5 was admitted on July 21, 2025 and discharged on December 9, 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.33 (a), the following will be implemented:
Beginning on 2/5/2026, the Clinical Supervisor will ensure that all counselors are completing the "Notification of Termination" in the clients record as needed. In addition, the Clinical Supervisor will ensure that the Notification of Termination includes the reason for the termination of treatment.
The Program Director will monitor the outcome of this plan, during monthly supervision with the Clinical Supervisor. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 7, 30 and 90 days following discharge.
Client #7 was admitted on April 14, 2025 and discharged on July 14, 2025. The 90 day follow up was due no later than October 14, 2025; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 19, 2024 licensing inspection.
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Plan of Correction
In an effort to address citation 709.53 (a) (11), the following will be implemented:
Beginning on 2/5/2026, the Program Coordinator will complete all follow ups at 7, 30, and 90 days post discharge. We have implemented a new system to measure the time frames to ensure compliance.
The Systems Manager will monitor the outcome of this plan on a monthly basis. |