INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 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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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 an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 2 was admitted on August 14, 2024 and was discharged on April 9, 2025. There was evidence of disclosures to a family member during a family counseling session on December 10, 2024; however, the record did not contain a client signed consent to release information form allowing the disclosures.
Client # 5 was admitted on February 14, 2025 and was active at the time of the inspection. There was evidence of disclosures to a family member during a family counseling session on May 7, 2025; however, the record did not contain a client signed consent to release information form allowing the disclosures.
This is a repeat citation from the April 19, 2024 and May 22, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director informed staff that all releases must be completed prior to family sessions for all participants. Once a family session is scheduled counselors are to review the client file to ensure all appropriate consents are on file. If appropriate consent is not on file, then the counselor will obtain consent prior to family member joining session.
This information was reviewed in clinical team meetings held on 5/23/25 and 5/30/25.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by program director and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client # 5 was admitted on February 14, 2025 and was active at the time of the inspection. The record contained a consent to release information form to the emergency contact dated February 26, 2025, but did not contain the client ' s signature.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director informed staff that all releases must be completed in person with the clients' written signature. If the client is not present a signature may be obtained via My Health Pointe platform for written signature. If a client needs to revoke a release of information they may do so by completing the Revoke release/request form and obtain clients written signature or verbal consent.
This information was reviewed in clinical team meetings held on 5/23/25 and 5/30/25.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by program director and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time. |
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 obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the May 22, 2023 and April 19, 2024, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the May 22, 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.
The Division Director will meet with the Program Director at least monthly in documented supervision sessions to review and identify barriers to the implementation of each action item. Any barriers noted will be addressed as appropriate.
The Division Director will report at least monthly to the Deputy Director regarding any outstanding items, identified barriers, or other areas requiring improvement. 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. |