INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31 to September 1, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure staff received at least 6 hours of HIV/AIDS and 4 hours of TB/STD within the first two years of employment in one of one applicable records.
Staff #1 was hired at the facility August 5, 2019 and still employed at time of inspection. Communicable disease training was due no later than August 5, 2021. There was no documentation provided for the completion of the trainings 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 training will be completed within the required timeframe.
The outstanding trainings for this individual will be completed as soon as they can be scheduled. This is anticipated to be no later than 12/31/26.
All staff members have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Gaudenzia Compliance Department will conduct a review of all POC action items 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 complete case consultations in four of seven outpatient client records.
Per agency policy and procedure, case consultations are to be completed every 90 days.
Client #1 admitted December 30, 2025 and discharged April 7, 2026. A case consultation due by March 30, 2026 but not completed prior to dischage.
Client #3 admitted January 13, 2026 and discharged May 14, 2026. A case consultation was due by April 13, 2026 but not completed until May 11, 2026.
Client #6 admitted January 28, 2026 and still a current client. A case consultation was due by April 28, 2026 but not completed until May 6, 2026.
Client #7 admitted February 3, 2026 and still a current client. A case consultation was due by May 4, 2026 but not completed until June 24, 2026.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 26, 2025 and August 21, 2024 licensing inspections.
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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 no later than 10/31/26. 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 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 Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
The Gaudenzia Compliance Department will conduct a review of all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed |
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 case consultations was submitted and approved by the Department for the August 26, 2025, and August 21, 2024 annual licensing inspections. Case consultations were again found to be a deficiency in the September 1, 2026 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area of the Plan of Correction.
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.
Any areas noted as not meeting the requirements listed above will be addressed with the Program Director in a documented supervision session note detailing any additional required actions to be taken to bring the program into full compliance.
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 |