INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on September 18, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway/Greentree 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of staff records, the facility failed to ensure clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision in one of three applicable records.
Staff #4 was hired as a clinical supervisor on February 17, 2025 and was in this position at the time of review. Staff #4 had no record of previous supervision experience in clinical services, as well as no record of completing a core curriculum in clinical supervision as of the time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff # 4 completed the DDAP Clinical Supervisor Foundation Training on October, 7, 2025 and the DDAP approved PESI Clinical Supervisor Training on October 12, 2025 to meet the requirements for qualifications of a clinical supervisor. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to complete comprehensive treatment plans within the time frame listed in the facility ' s policy and procedures in four of seven applicable records.
Prior to July 21, 2025, the facility ' s policy and procedure stated comprehensive treatment plans were to be completed within three visits for the outpatient level of care. Effective July 21, 2025 the facility ' s policy and procedure stated a comprehensive treatment plan was due within 30 days of admission for the outpatient level of care.
Client #1 was admitted to the outpatient level of care on April 21, 2025 and was active at the time of review. Client #1 ' s comprehensive treatment plan was due to be completed on April 24, 2025; however, the comprehensive treatment plan was not completed until September 12, 2025.
Client #2 was admitted to the outpatient level of care on May 28, 2025 and was discharged August 5, 2025. Client #2 ' s comprehensive treatment plan was due to be completed on June 3, 2025; however, the comprehensive treatment plan was not completed prior to discharge.
Client #3 was admitted to the outpatient level of care on February 10, 2025 and was discharged July 22, 2025. Client #3 ' s comprehensive treatment plan was due to be completed on February 13, 2025; however, the comprehensive treatment plan was not completed until February 18, 2025.
Client #7 was admitted to the outpatient level of care on March 17, 2025 and was discharged July 10, 2025. Client #7 ' s comprehensive treatment plan was due to be completed on May 5, 2025; however, the comprehensive treatment plan was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion and timeline for the comprehensive treatment plans by October 31, 2025. The Program Manager will be responsible for verifying timely completion of the comprehensive treatment plans by completing random chart supervision in 10% of the active charts monthly. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to ensure that individual treatment plans include type and frequency of treatment and rehabilitation services in two of five applicable records.
Client #1 was admitted to the outpatient level of care on April 21, 2025 and was active at the time of review. Client #1 ' s treatment plan dated September 12, 2025 did not contain a type and frequency of treatment and rehabilitation services.
Client #3 was admitted to the outpatient level of care on February 10, 2025 and was discharged July 22, 2025. Client #3 ' s treatment plan dated February 18, 2025 did not contain a type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion of the treatment plan to include type and frequency of treatment by October 31, 2025. The Program Manager will be responsible for verifying time and frequency is included in treatment plans by completing random chart supervision in 10% of the active charts monthly. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to ensure that individual treatment plans include proposed type of support services in four of five applicable records.
Client #1 was admitted to the outpatient level of care on April 21, 2025 and was active at the time of review.. Client #1 ' s treatment plan dated September 12, 2025 did not contain proposed type of support services.
Client #3 was admitted to the outpatient level of care on February 10, 2025 and was discharged July 22, 2025. Client #3 ' s treatment plan dated February 18, 2025 did not contain proposed type of support services.
Client #4 was admitted to the outpatient level of care on June 4, 2025 and was discharged August 11, 2025. Client #4 ' s treatment plan dated June 25, 2025 did not contain proposed type of support services.
Client #6 was admitted to the outpatient level of care on May 5, 2025 and was discharged August 28, 2025. Client #6 ' s treatment plan dated May 12, 2025 did not contain proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion of the treatment plan to include support services by October 31, 2025. The Program Manager will be responsible for verifying support services are included in treatment plans by completing random chart supervision in 10% of the active charts monthly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every 60 days in two of three applicable records.
Client #3 was admitted to the outpatient level of care on February 10, 2025 and was discharged July 22, 2025. Client #3 had a treatment plan completed on February 18, 2025. The next treatment plan update was due no later than April 18, 2025; however, the next treatment plan update was not completed until May 5, 2025.
Client #6 was admitted to the outpatient level of care on May 5, 2025 and was discharged August 28, 2025. Client #6 had a treatment plan completed on May 12, 2025. The next treatment plan update was due no later than July 12, 2025; however, no treatment plan update was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion and timeline for treatment plan reviews by October 31, 2025. The Program Manager will be responsible for verifying timely completion of the review treatment plans by completing random chart supervision in 10% of the active charts monthly. |