INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 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 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of seven client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed.
Client #1 was admitted on October 20, 2025, and was still active at the time of the inspection. There was documentation that was disclosed to the county court on February 20, 2026 and April 15, 2026; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.
This is a repeat citation from April 04, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An informed and voluntary consent from the client for the disclosure of information contained in the client record will be completed fully, correctly, and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in two out of seven client records reviewed.
Client #1 was admitted on October 20, 2025, and was still active at the time of the inspection. A consent form signed and dated October 20, 2025, to the funder, did not have documentation that the client was offered a copy of the consent form.
Client #3 was admitted on October 27, 2025, and was still active at the time of the inspection. A consent form signed and dated February 6, 2026, for CYS, did not have documentation that the client was offered a copy of the consent form. Additionally, a consent form signed and dated February 20, 2026, and March 06, 2026, respectfully, for a lawyer and a family member, did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An informed and voluntary consent from the client for the disclosure of information contained in the client record will be completed fully, correctly, and in a timely manner to include indicating the client was offered a copy of the consent.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 document and ensure a comprehensive treatment plan shall be developed with the client and within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.
Client #2 was admitted on August 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than September 06, 2025; however, it was not completed until September 09, 2025.
Client #4 was admitted on November 28, 2025 and discharged on February 26, 2026. A comprehensive treatment plan was due no later than December 28, 2025; however, it was not completed until January 23, 2026; and there was no documentation that it was developed with the client.
Client #6 was admitted on July 23, 2025 and discharged on January 08, 2026. A comprehensive treatment plan was completed on July 31, 2025; however, there was no documentation that it was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans will be completed correctly and in a timely manner following Gaudenzia's policies.
If a client is not available or is a no-show for the session during which the Treatment Plan is scheduled to be completed, this will be documented in a note to chart. Prior to receiving any additional services, the Treatment Plan will be updated with the client.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include, but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #1 was admitted on October 20, 2025 and was still active at the time of the inspection. An initial individual treatment plan was developed on November 06, 2025 with no type or frequency identified.
Client #2 was admitted on August 06, 2025 and was still active at the time of the inspection. An initial individual treatment plan was developed on September 09, 2025 with no type or frequency identified.
Client #7 was admitted on January 30, 2026 and discharged on April 09, 2026. An initial individual treatment plan was developed on February 06, 2026 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans in the client record will be completed fully, correctly, and in a timely manner to include the frequency of treatment and rehabilitation services.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will ensure all Treatment Plans are completed with the required information including the frequency of treatment and rehabilitation services prior to signing the Treatment Plan. If any information is missing, the Treatment Plan will be rejected, and the clinician will complete an updated Treatment Plan for review.
The Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #1 was admitted on October 20, 2025 and was still active at the time of the inspection. A case consultation was due no later than January 20, 2026; however, one was not completed until March 30, 2026.
Client #2 was admitted on August 06, 2025 and was still active at the time of the inspection. A case consultation was due no later than November 06, 2025; however, one was not completed until February 13, 2026.
Client #3 was admitted on October 27, 2027 and was still active at the time of the inspection. There was no documentation in the client record of case consultation notes at the time of the inspection.
Client #6 was admitted on July 23, 2025 and discharged on January 08, 2026. A case consultation was due no later than October 23, 2025; however, one was not completed until January 08, 2026.
This is a repeat citation from April 04, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner to include Case Consultation Notes.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed
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