INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 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 Kindred House 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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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident that required the presence of police and/or ambulance personnel at the facility.
On May 10, 2025, there was an incident at the facility that required the presence of ambulance personnel on-site. There was no documentation indicating the incident was reported to the Department at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The report in question was submitted by the Program Director via the Electronic Reporting System (ERS) on 5/12/26.
All future reports will be submitted by the Program Director via the Electronic Reporting System within 3 business days.
All internal incident reports will be submitted to the Program Director within 24 hours of the incident to make the determination as to whether the incident is of the type which would be classified as an Unusual Incident per the regulation.
The Division Director will meet with the Program Director at least monthly in documented supervision sessions which will include review of incident reports during that time periods as well as confirmation of any required external reporting. Any which were not reported to DDAP will be reported immediately.
The Division Director will report at least monthly to the Regional Executive Director regarding any issues in this area, identified barriers, or other areas requiring improvement.
The Gaudenzia Compliance Department will conduct a review of any citations within 90 days to ensure full implementation, and coordinate support, where needed.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 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 thirty days in two of six applicable client records reviewed.
Client # 1 was admitted on January 6, 2026 and was still active at the time of the inspection. A treatment plan update was completed on February 12, 2026 and the next update was due no later than March 12, 2026; however, the update was not completed until March 18, 2026.
Client # 5 was admitted on February 4, 2026 and was discharged on March 26, 2026. The individual treatment and rehabilitation plan was completed on February 17, 2026 and the first update was due no later than March 17, 2026; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans in the client record will be completed fully, correctly, and in a timely manner to include updating the treatment plan in accordance with Gaudenzia's policy.
If a client is not available to review and update their Treatment Plan due to being away from the facility when the treatment plan is due, this will be documented in a note to chart. The treatment plan will be reviewed, updated and signed by the client upon their return to the facility.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/10/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; 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 the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
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