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, GateHouse Mountville 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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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 in the use of the fire extinguishers upon employment.
Employee #5 was hired on March 24, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed; however, the training certificate was not dated.
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 (c) (4), the following will be implemented:
Beginning on 2/2/2026, all new hires will complete the "Emergency Procedures" training that includes the fire safety training within one week of being hired. All training certificates will include the staff person's name and date that the training was completed.
In addition, employee #5 will complete this training again by 2/6/2026 to ensure that there is a certificate of completion with the completed date.
The Human Resource Generalist will ensure that this action step is completed during the orientation for all new hires. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #5 was hired on March 24, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed; however, the training certificate was not dated.
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 2/2/2026, the Residential Program Supervisor will ensure that employee #5 is trained by 2/6/2026 on how to complete all aspects of a fire drill and other emergency procedures.
The Program Director will ensure that this action step is completed. |