INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 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 DRC 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was completed for each employee, appropriate to that employee ' s skill level and with input from both the employee and supervisor, in four of five personnel records reviewed.
Employee #2 was hired as the facility director on June 1, 2025. There was no current individual training plan for the current position documented in the record at the time of inspection.
Employee #3 was hired as a counselor on April 4, 2024. There was no current individual training plan for the current position documented in the record at the time of inspection.
Employee #4 was hired as a counselor on January 6, 2025. There was no current individual training plan for the current position documented in the record at the time of inspection.
Employee #5 was hired as counselor on August 1, 2025. There was no current individual training plan for the current position documented in the record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- All current employees have now been provided with updated individual training plans completed with input from both the employee and supervisor. These training plans have been reviewed and signed by the employee.
Preventive Measures:
- A standardized training plan has been implemented for all new hires which is individualized based on the staff member's skill level and position.
- Supervisors will ensure training plans are completed during onboarding.
Monitoring:
The Program Director will conduct quarterly personnel file reviews to ensure ongoing compliance. Any staff member found to not have an individual training plan on file will have one completed immediately.
Completion Date:
All corrective actions will be implemented by 12/31/25
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
At the time of the inspection, there was a group counseling session, being conducted between 9:00 a.m. and 9:10 a.m., that could be seen and heard from outside the room as the door was open during the session.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- Staff were immediately directed to keep counseling room doors closed during all sessions to maintain privacy.
- The incident was reviewed with the team, and expectations were reinforced in a documented training on 12/18/25.
Preventive Measures:
- A reminder has been posted on all counseling room doors stating: "Door must remain closed during all sessions."
Monitoring:
The Program Director will conduct weekly walk-throughs to verify that privacy is maintained during all counseling activities and will also monitor informally during daily interactions.
If at any time it is noted that privacy is not being maintained, the supervisor will meet with the staff member conducting the session in a documented supervision session to reinforce privacy regulations.
Completion Date:
All corrective actions will be implemented by 12/18/25.
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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 and the facility's policies and procedures, the facility failed to develop an individual treatment and rehabilitation plan with the client in three of six applicable client records reviewed.
The facility policy and procedures manual stated in dividual treatment and rehabilitation plans would be completed within 30 days of admission.
Client # 1 was admitted on June 18, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by July 18, 2025; however, there was no documentation of a treatment plan in the record at the time of inspection.
Client # 3 was admitted on August 23, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by September 23, 2025; however, there was no documentation of a treatment plan in the record at the time of inspection.
Client # 7 was admitted on March 18, 2025 and was discharged on May 26, 2025. The individual treatment and rehabilitation plan was due to be completed by June 26, 2025; however, there was no documentation of a treatment plan in the record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- Treatment plans for the active clients have now been completed and placed in their records.
- The clinical team has been re-trained on 12/18/25 regarding the 30-day requirement.
Preventive Measures:
- A tracking system has been implemented to monitor treatment plan due dates for all new admissions.
- Supervisors will complete weekly chart reviews to ensure treatment plans are completed on time.
- Compliance will be reviewed during clinical meetings, with follow-up as needed.
- Any issues noted will be reviewed with the clinician responsible in a documented supervision session and corrected within 48 hours.
Monitoring:
The Program Director will conduct monthly chart reviews to ensure continued compliance with all treatment plan deadlines.
Completion Date:
All corrective actions will be fully implemented by 12/31/25.
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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 treatment and rehabilitation plans were reviewed and updated at least every 60 days in one of two applicable client records reviewed.
Client # 5 was admitted on January 3, 2025 and was discharged on June 1, 2025. The individual treatment and rehabilitation plan was completed on January 18, 2025 and the first update was due to be completed no later than March 18, 2025; however, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- Treatment plans for the active clients have now been completed and placed in their records.
- The clinical team will be re-trained on 12/19/25 regarding the 60-day requirement.
Preventive Measures:
- A tracking system has been implemented to monitor treatment plan due dates for all new admissions.
- Supervisors will complete weekly chart reviews to ensure treatment plans are completed on time.
- Compliance will be reviewed during clinical meetings, with follow-up as needed.
- Any issues noted will be reviewed with the clinician responsible in a documented supervision session and corrected within 48 hours.
Monitoring:
The Program Director will conduct monthly chart reviews to ensure continued compliance with all treatment plan deadlines.
Completion Date:
All corrective actions will be fully implemented by 12/31/25.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure counseling services were provided according to the individual treatment and rehabilitation plan in one of three applicable client records reviewed.
Client # 5 was admitted on January 3, 2025 and was discharged on June 1, 2025. The individual treatment and rehabilitation plan was completed on January 18, 2025 and the plan indicated the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented, in the record, from the last counseling session held on May 1, 2025 through the discharge date.
This is a repeat citation from the January 22, 2025 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- The client record was reviewed, and services were updated to reflect alignment with the treatment plan.
- The requirement to provide and document services consistent with each client's treatment goals was reviewed with all staff in a documented in-service training on 12/18/25.
Preventive Measures:
- Counselors will review each client's treatment plan prior to sessions to ensure service alignment. This included documentation of reasons why a client was not in attendance for scheduled sessions.
- Supervisors will conduct weekly chart reviews to confirm that services match treatment plan objectives.
Monitoring:
The Program Director will incorporate service-to-plan compliance into monthly chart reviews.
Any issues noted will be reviewed with the clinician responsible in a documented supervision session.
Completion Date:
All corrective actions will be implemented by 12/31/25.
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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 and the facility's policies and procedures, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in seven of seven client records reviewed.
The facility policy and procedure manual stated case consultation notes are to occur and be completed every 30 days; however, there was no documentation of case consultation notes in every client record reviewed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- Case consultation notes have been completed and added to all current client records.
- The requirement for timely case consultation documentation we reviewed with all staff during a documented in-service training on 12/18/25.
Preventive Measures:
- A tracking system for 30-day case consultation deadlines has been implemented.
- Supervisors will conduct weekly chart reviews to ensure all required notes are completed.
Monitoring:
The Program Director will include case consultation compliance in monthly chart reviews.
Any issues noted will be reviewed with the clinician responsible in a documented supervision session.
Completion Date:
All corrective actions will be implemented by 12/31/25.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of aftercare plans, in two of two applicable client records reviewed.
Client # 4 was admitted on November 19, 2024 and was discharged on May 1, 2025. There was no aftercare plan documented in the record at the time of the inspection.
Client # 6 was admitted on April 18, 2025 and was discharged on July 7, 2025. There was no aftercare plan documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- All current client records have been reviewed, and case consultation notes have been completed and added, where applicable.
- The requirement for case consultation notes every 30 days was reviewed with all staff in a documented in-service training on 12/18/25.
Preventive Measures:
- A tracking system has been established to monitor the 30-day due dates for case consultations.
- Supervisors will conduct weekly chart reviews to ensure all required notes are completed on time.
Monitoring:
The Program Director will perform monthly reviews to ensure continued compliance with documentation requirements.
Any issues noted will be reviewed with the clinician responsible in a documented supervision session.
Completion Date:
All corrective actions will be implemented by 12/31/25.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policies and procedures, the project failed to maintain a complete client record, which is to include documentation of a discharge summary, in four of four applicable client records reviewed.
The facility policy and procedures manual stated discharge summaries are to be completed within five days of discharge.
Client # 4 was admitted on November 19, 2024, and was discharged on May 1, 2025. The discharge summary was not documented in the record until October 16, 2025.
Client # 5 was admitted on January 3, 2025 and was discharged on June 1, 2025. The discharge summary was not documented in the record until August 12, 2025.
Client # 6 was admitted on April 18, 2025 and was discharged on July 7, 2025. The discharge summary was not documented in the record until October 16, 2025.
Client # 7 was admitted on March 18, 2025 and was discharged on May 26, 2025. The discharge summary was not documented in the record until October 16, 2025.
This is a repeat citation from the January 22, 2025 and November 28, 2023 annual licensing renewal inspections, and the May 23, 2024 provisional license follow-up inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- All missing discharge summaries have been completed and added to the respective client records.
- The requirement for timely completion of a discharge summary was reviewed with all staff in a documented in-service training on 12/19/25.
Preventive Measures:
- A discharge checklist has been implemented to ensure summaries are completed promptly.
- Supervisors will review all discharges weekly to verify that documentation is complete and timely.
Monitoring:
The Program Director will include discharge summary compliance in monthly chart reviews.
Any issues noted will be reviewed with the clinician responsible in a documented supervision session.
Completion Date:
All corrective actions will be implemented by 12/31/25.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in three of four applicable client records reviewed.
Client # 4 was admitted on November 19, 2024 and was discharged on May 1, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 5 was admitted on January 3, 2025 and was discharged on June 1, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 6 was admitted on April 18, 2025 and was discharged on July 7, 2025. There was no follow-up information documented in the client record at the time of the inspection.
This is a repeat citation from the January 22, 2025 and November 28, 2023 annual licensing renewal inspections, and the May 23, 2024 provisional license follow up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Corrective Action:
- Follow-up information has now been completed and added to all current applicable client records.
- The requirement to document follow-up information was reviewed with all staff in a documented in-service training on 12/19/25.
Preventive Measures:
- A follow-up tracking system has been implemented to ensure timely completion.
- Supervisors will review discharged client records weekly to verify follow-up documentation completion.
Monitoring:
The Program Director will include follow-up documentation compliance in monthly chart reviews.
Any issues noted will be reviewed with the clinician responsible in a documented supervision session.
Completion Date:
All corrective actions will be implemented by 12/31/25.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to document follow-up information in the record was submitted and approved by the Department for the November 28, 2023 and January 22, 2025 annual licensing inspections, as well as the provisional follow up inspection on May 23, 2024. Failing to document follow-up information in the record was again found to be a deficiency in the November 13, 2025 licensing inspection.
A plan of correction for failing to document discharge summaries in the record was submitted and approved by the Department for the November 28, 2023 and January 22, 2025 annual licensing inspections, as well as the provisional follow up inspection on May 23, 2024. Failing to complete discharge summaries in the record was again found to be a deficiency in the November 13, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area above.
Implementation will be monitored through at least monthly reviews of the Plan of Correction and documented follow up with any staff member found to be deviating from the action items listed.
Corrective Action:
- All previously approved POCs were reviewed, and outstanding items have now been completed.
Preventive Measures:
- A compliance tracking log has been created to monitor all POC responsibilities and deadlines.
- Supervisors will verify completion of all POC-related tasks during weekly leadership meetings.
Monitoring:
The Program Director will conduct monthly reviews to ensure ongoing adherence to all active and future POCs.
Completion Date:
All corrective actions will be implemented by 12/31/25.
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