INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-13, 2025 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a review of the facilities physical plant, the facility failed to ensure frozen foods were kept at or below 0 degrees Fahrenheit.
The freezer located in the kitchen had a thermometer reading of 16 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Program staff will document the temperature of refrigerators and freezers nightly on third shift rounds.
Person(s) Responsible: Staff on duty
Target Completion Date: Ongoing
2. Program staff will ensure the appliances are not overstocked to ensure proper air flow.
Person(s) Responsible: All staff
Target Completion Date: Ongoing
3. Program staff will notify a supervisor via email or shift note if readings are recorded above 0 degrees Fahrenheit.
Person(s) Responsible: All staff
Target Completion Date: Ongoing
4. Administrative Assistant or other designated employee will identify any issues with appliances on the monthly safety report and submit the report to the Program Director.
Person(s) Responsible: AA/other designated staff
Target Completion Date: Ongoing
5. Program Director, Clinical Supervisor, or Recovery Support Supervisor will submit maintenance tickets as needed to address faulty appliances.
Person(s) Responsible: Program Director, Clinical Supervisor, Recovery Support Supervisor
Target Completion Date: Ongoing as needed? Work Order #111377 submitted on 9/4/2025
6. The kitchen freezer has been emptied and will be monitored for compliance to next week. The program will resume using it once verified that it is keeping temps at or below zero degrees Fahrenheit and is safe to use.
Person(s) Responsible: Program Director, Staff on Duty, Maintenance dept. staff
Target Completion Date: 9/15/2025
7. Program Director will work with the Maintenance department to determine if appliances can be repaired if needed. If not, Program Director will work with the Purchasing and Maintenance Depts. to order a new appliance.
Person(s) Responsible: Program Director, Maintenance dept. staff, Purchasing dept. staff
Target Completion Date: 9/19/2025 |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
One fire extinguisher located in the carriage house next to the offices was last inspected and approved April 2024.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
1. Administrative Assistant (AA) or other designated employee will complete monthly inspections of fire extinguishers and document checks on the provided tags.
Person(s) Responsible: AA/other designated staff
Target Completion Date: Ongoing
2. Administrative Assistant or other designated employee will identify any issues with fire extinguishers on the monthly safety meeting report and submit the report to the Program Director.
Person(s) Responsible: AA/other designated staff
Target Completion Date: Ongoing
3. Administrative Assistant or other designated employee will contact Summit Fire and Security (814-456-9634) to report issues with fire extinguishers and schedule service calls.
Person(s) Responsible: AA/other designated staff
Target Completion Date: Program Director contacted Summit Fire and Security on 8/21/2025 ? fire extinguisher on the second floor of the Carriage House was serviced on 8/25/2025
4. Program staff will cooperate with Summit Fire and Security (or other entity designated by Gaudenzia, Inc.) to ensure that all fire extinguishers are checked/serviced/replaced as needed annually.
Person(s) Responsible: All staff
Target Completion Date: Ongoing |