INITIAL COMMENTS
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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 ZRDP6701 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.
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Plan of Correction
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§ 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.
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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.
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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.
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Observations
Based on three of seven resident records reviewed, the facility failed to provide a consent to residency which must be signed by the resident within 24 hours.Resident #3 was admitted on February 12, 2026, and was still a resident at the time of the inspection. There was not a consent to residency provided in the resident record.Resident #4 was admitted on February 24, 2026, and was still a resident at the time of the inspection. There was not a consent to residency provided in the resident record.Resident #7 was admitted on September 17, 2025, and discharged December 11, 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 4/15/26 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.
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§ 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.
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Observations
Based on two of three discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.Resident #5 was admitted on May 7, 2025, and was discharged July 23, 2025. There was no documentation of an end to residency in the resident record.Resident #7 was admitted on January 23, 2025, and discharged September 18, 2025. 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
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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. |
§ 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 one of four applicable 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 May 7, 2025, and was discharged July 23, 2025. There was no 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 4/16/2026, The GTL Coordinator will contact the residents designated emergency contact within 12 hours of the following events:
Residency was ended, resident did not return to the recovery house within 3 hours of curfew and did not call the GTL Coordinator, resident decided to end residence prematurely, resident has relapsed, or the resident has been hospitalized.
The Program Director will monitor this action step during monthly supervision with the GTL Coordinator. |