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 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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§ 717.17(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 February 27, 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.
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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 September 11, 2025, and discharged October 13, 2025. There was no documentation of an end to residency in the resident record.Resident # 7 was admitted on March 3, 2025, and discharged March 28, 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.
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