INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 11-13, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of administrative information, the facility failed to provide academic qualification for a counselor in one of one applicable records reviewed.
Staff #3 was hired on January 21, 2025 as a counselor and still employed at the time of inspection. Staff #3 failed to provide verification of a qualifying degree.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Verification of a qualifying degree was obtained for this staff member and provided to DDAP on 8/28/25.
Going forward, the Director and program supervisors will ensure that this is present for all staff members at the time of hire. Staff files for all newly hired staff will be reviewed at the end of their first month of employment to ensure compliance.
|
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.
|
Observations
Based on a review of the staffing records, the facility failed to ensure all personnel were instructed in the use of fire extinguishers in one of four applicable records reviewed.
Staff #3 was hired as a counselor on January 21, 2025 and still a current employee. Fire extinguisher training was due upon hire but not completed until March 13, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff member #3 completed the actual training, but did not complete the evaluation for that training. This has been completed, 9/11/25.
Going forward, Supervisors will ensure that after staff members complete a training, the evaluation is completed as well.
Supervisors will check the training system to ensure fire extinguisher training is completed for all new hires within their first 3 days of hire.
Supervisors will also spot-check trainings during monthly individual supervision with their direct reports to further ensure compliance.
|
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills once a month.
Reviewed fire drills from August 2024 to July 2025. No fire drill was conducted in October 2024.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Fire drills will be completed monthly for each shift as per DDAP regulations by the Director, RSP Supervisor, or 3rd shift RSP. Fire drills have been completed on a monthly basis since a new Director was hired and will continue to be done monthly as required by DDAP. The fire drills will be documented, and uploaded into the organization's SharePoint system, to ensure visibility and oversight by senior management. Any issues noted will be addressed in monthly supervision. |
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.
|
Observations
Based on a review of the staffing records, the facility failed to ensure that all personnel were trained to perform tasks during emergencies in one of four applicable records reviewed.
Staff #3 was hired as a counselor on January 21, 2025 and still a current employee. Verification of the completed training was due upon hire but not completed until March 13, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff member #3 completed the actual training but did not complete the evaluation for that training. This is now complete, 9/11/25.
Going forward, Supervisors will ensure that after staff members complete a training, the evaluation is completed as well. Supervisors will also ensure that after the staff members complete a training, the staff member will review assigned tasks and practice performance of such tasks.
Supervisors will also spot-check trainings during monthly individual supervision with their direct reports to further ensure compliance.
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
Reviewed fire drills from August 2024 to July 2025. An overnight fire drill was due by December 2024 but not conducted until May 2025.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Fire drills will be during sleeping hours at least every 6 months, as per DDAP regulations. The Program Director will oversee the fire drill process, and ensure that this is done. The fire drills will be documented (including the times the drills occurred), and uploaded into the organization's SharePoint system, to ensure visibility and oversight by senior management. Any issues noted will be addressed in supervision. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel records, the facility failed to ensure annual written individual staff performance evaluations, were reviewed and signed by the employee in one of three applicable records reviewed.
The facility's policy and procedure manual states the annual job performance evaluations are due at the beginning of each calendar year and to be completed and signed by February 28 each year.
Employee #5 was hired as a counselor on December 7, 2020 and is still in that position at the time of the inspection. The annual work performance evaluation was completed but not signed by employee at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 8, 2025 licensing inspection.
|
Plan of Correction
Employee #5's evaluation was signed on 6/12/25.
Going forward, performance evaluations will be reviewed with the staff member during a documented supervision session. Staff members will sign to indicate acknowledgment at that time.
All staff files will be reviewed by program management during the month of February, to ensure that all have been signed.
|
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.
|
Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident. The facility had unusual incidents occur on June 20, June 22, June 30, July 10, and July 14, 2025 all which involved police, EMS, or fire personnel onsite and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The reports in question were submitted by the Program Director via the Electronic Reporting System (ERS).
All future reports will be submitted by the Program Director via the Electronic Reporting System (ERS) 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 a type which would be classified as an Unusual Incident per 709.34.
The Regional Executive Director will meet with the Program Director at least monthly in documented supervision sessions which will include review of incident reports during that time period as well as confirmation of any required external reporting, and any issues / identified barriers/or other areas requiring improvement. Any which were not reported to DDAP will be reported immediately.
|