INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on June 25 - 26, 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 - Coal Township 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:
|
Plan of Correction
|
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
|
Observations
Based on a physical plant inspection, the facility failed to maintain counseling areas with furnishings in good repair. In both the male and female lounges, which are used for group sessions, the couches are torn.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
To correct this deficiency, the damaged couches were replaced with new furniture on July 22, 2026. The new furnishings have been placed in the male and female lounges, ensuring that all counseling areas are maintained in a clean, safe, and professional condition that supports therapeutic programming.
To prevent recurrence, the Program Director and designated maintenance staff will conduct routine inspections of all client and counseling areas to identify any furnishings or equipment that require repair or replacement. Any items found to be damaged or no longer suitable for use will be addressed promptly through repair or replacement in accordance with facility standards. These inspections will take place monthly. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill logs and discussion with facility staff, the facility failed to conduct unannounced fire drills at least once a month in the two mobile units. There were no drills conducted from May 2025 through May 2026.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
To correct this deficiency, the first unannounced fire drill for the mobile units was conducted on June 26, 2026, and documentation was completed and maintained in the appropriate fire drill log.
To prevent recurrence, the Program Director has implemented a monthly fire drill schedule for both mobile units to ensure that unannounced fire drills are conducted and documented at least once each month in accordance with DDAP regulations. The Program Director or designee will review fire drill documentation monthly to verify completion and ensure ongoing compliance. Any missed or incomplete drill will be addressed immediately. |