INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28-29, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection S7V96701 The Gatehouse was found to not 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.
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Plan of Correction
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§ 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.
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Observations
Based on four 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 December 10, 2024, and is still a resident. There was not a consent to residency provided in the resident record.
Resident #2 was admitted on November 26, 2024, and discharged August 29, 2024. There was not a consent to residency provided in the resident record.
Resident #5 was admitted on July 11, 2024, and discharged December 17, 2024. There was not a consent to residency provided in the resident record.
Resident #6 was admitted on July 22, 2024, and discharged November 15, 2025. 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.
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Plan of Correction
In an effort to address citation 717.22(b)(4), the following will be implemented:
Beginning on 6/2/2025, the House Manager will ensure that all GateHouse Transitional Housing staff are trained on completing the consent to residency with all new residents within 24 hours of their arrival. The signed consent to residency will be filed in the residents chart.
The House Manager will monitor this plan during monthly supervision.
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§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
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Observations
Based on two of five discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident #5 was admitted on July 11, 2024, and discharged December 17, 2024. There was not a notification to the emergency contact provided in the resident record.
Resident #6 was admitted on July 22, 2024, and discharged November 15, 2024. There was not a notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In an effort to address citation 717.27, the following will be implemented:
Beginning on 6/2/2025, the House Manager will ensure that all GateHouse Transitional Living staff are trained on the requirement to notify the residents emergency contact if and when the resident decides to end their residency, does not return to the residence, GTL ends the residency, or in the case of a medical emergency or death, within 12 hours of the event. The contact will be documented in the residents record.
The House Manager will monitor this plan monthly while providing supervision to the GTL staff.
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§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The water temperature was read at 131 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In an effort to address citation 717.29 (e) (3), the following will be implemented:
Beginning on 6/2/2025, the Maintenance Department will adjust the water heater to 120F.
The GTL Coordinator will monitor the temperature of the hot water monthly during housing inspections.
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