INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor met the educational qualifications of the position in one of two applicable personnel records reviewed
Employee #4 was hired as a counselor on October 14, 2024. At the time of the inspection, there was no qualifying educational degree documented in the personnel record; therefore, the DDAP representative was unable to review and verify if the employee was qualified for the position of counselor.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, upon an employee's acceptance of the position and first day of employment, Program Director will work with Human Resources to ensure that counselors have an approved degree as outlined by DDAP.
Addendum: Employee Degree was uploaded into employee file on 6/5/25 and her degree transcripts were uploaded on 7/7/25. A degree exception was also submitted to DDAP on 6/22/25. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
At the time of the inspection, there was an empty paper towel dispenser in the shared client bathroom and there was no supplemental mechanical dryer.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Program Director, placed a work worder to address defective hand dryer. By July 15, 2025, the Program Director will have met with the RSP Supervisor to review the maintenance request process and ensure RSP staff are re-trained by August 1, 2025, regarding the expectations of the client's bathrooms. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment in two of two applicable personnel records reviewed.
Employee # 3 was hired as a counselor on October 21, 2024. There was documentation in the personnel record indicating the fire extinguisher training was completed on April 15, 2025.
Employee # 4 was hired as a counselor on October 14, 2024. There was documentation in the personnel record indicating the fire extinguisher training was completed on April 10, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, all new hires will receive Fire Safety training within the week of employment. The Program Director will meet with the administrative team to ensure that this process is followed. The Program Director will monitor new hire training records, to ensure that fire extinguisher training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel, on all shifts, were trained to perform assigned tasks during emergencies in two of two applicable personnel records reviewed.
Employee # 3 was hired as a counselor on October 21, 2024. There was documentation in the personnel record indicating the emergency preparedness training was completed on April 15, 2025.
Employee # 4 was hired as a counselor on October 14, 2024. There was documentation in the personnel record indicating the emergency preparedness training was completed on April 10, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, all new hires will receive emergency preparedness training within the week of employment. The Program Director will meet with the administrative team to ensure that this process is followed. The Program Director will monitor new training records, to ensure that emergency preparedness training is completed. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, conducted on May 28, 2025, the facility failed to maintain protective caps over each electrical outlet within the facility.
At the time of the inspection, there were outlets in client rooms 201, 202, 203, 204, 206, 207, 208, 209, 210, 211 and 212 and in the common area of the administrative suite which were missing child protective caps.
This is a repeat citation from the June 8, 2023 and May 15, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, Protective Caps were placed on all of the unused outlets. The RSP staff will conduct daily spot checks and replace any caps that may have been removed. The RSP Supervisor will conduct weekly checks and ensure that there are additional protective caps readily available. |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical plant inspection, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks.
At the time of the inspection, there was laundry detergent, bleach, and a variety of other hazardous cleaning products left unsecured on the windowsill in client room 210.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, The RSP Supervisor and RSP staff will monitor cleaning supplies that are utilized within the facility and ensure that they are properly stored away by both staff and clients in a locked storage area. By August 30th the RSP Supervisor will retrain all staff in how to complete thorough room checks daily in an all-staff meeting. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made to on consent to release information forms in one of seven records reviewed.
Client # 1 was admitted on April 28, 2025 and was active at the time of inspection. There was a release of information form, signed by the client on May 12, 2025, which did not include documentation of the name of the person, agency, or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, Program Director will complete chart audits during admission to ensure that documentation is filled out correctly. By September 2025, The Program Director will ensure that staff are in attendance for documentation training that is offered within the organization, as well as reviewing proper documentation procedures during staff supervision.
Addendum: Correction was made in the client's chart on 6/27/25.
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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 personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for maintaining protective caps over each electrical outlet was submitted and approved by the Department for the June 8, 2023 and May 15, 2024 annual licensing inspections. Failing to maintain protective caps over each electrical outlet was again found to be a deficiency in the May 28, 2025 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, the Program Director will collaborate with the Division Director to monitor and review the plan of correction (POC) at least once a month to ensure that the processes that have been put in placed are being carried out. |