INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Winner Co-Occuring Women and Children Program 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 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's May 2025 through May 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided indicating a fire drill was completed during the months of September 2025 through April 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills were not conducted during the timeframe of September 2025 through April 2026 during an ongoing temporary closure of the facility. Program Management has been made aware that fire drills need to be completed and documented even while the program is not in full operation.
The Division Director will ensure fire drills are completed at least once per month and documented appropriately until the program is in full operation. When the facility re-opens, the Program Director will ensure the fire drills are completed and documented as required.
The Program Director will review each fire drill held and documented to ensure all of the necessary components are included in the fire drill log.
The Division Director will review the fire drill log on a quarterly basis to ensure all documentation is complete.
The Gaudenzia Compliance Department will conduct a review of the action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of the facility's unusual incident report log, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
There were three separate incidents documented in the incident report log, dated June 18, 2025, June 24, 2025, and July 8, 2025, where emergency medical personnel were called to the facility; however, tall three of the incidents were not reported to the Department as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All future reports will be submitted by the Program Director via the Electronic Reporting System within 3 business days.
All internal incident reports will be submitted to the Program Director within 24 hours of the incident to make the determination as to whether the incident is of the type which would be classified as an Unusual Incident Report.
The Division Director will meet with the Program Director at least monthly in documented supervision sessions which will include review of incident reports during that time period as well as confirmation of any required external reporting. Any which were not reported to DDAP will be done so immediately.
The Division Director will report monthly to the Regional Executive Director regarding any issues in this area, identified barriers, or other areas requiring improvement.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation and coordinate support where needed. |