INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29, 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 Together 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received at least 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training using a Department approved curriculum within the regulatory time frame in one of one applicable personnel records reviewed.
Employee # 6 was hired as recovery support staff on January 6, 2023. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due to be completed no later than January 6, 2025; however, the tuberculosis, sexually transmitted diseases, and other health related topics training was completed on April 18, 2025 and the HIV/AIDS training was not completed as of the date of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe. Outstanding training will be completed absolutely as soon as they can be scheduled. This is anticipated to be no later than 7/16/25. All staff members have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements. The Supervisor will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion. Certificates of completion as well as Evaluations will be maintained in the staff file. The Clinical Supervisor and Program Director will review the Individual Training Plans weekly for new hires, and at least quarterly for all staff. Staff who have upcoming training due dates within the next quarter will be reminded of this and the Supervisor will work with them to schedule training sessions prior to the due dates and will monitor to ensure full and timely completion. If any issues are noted with staff failing to complete scheduled trainings, this will be specifically addressed with them in a documented supervision session with a clear plan to have all trainings completed. If any issues are noted with unavailability of required training session opportunities, this will be addressed with the Division Director and the Deputy Director to assist in advocating with the training provider. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure cold food was kept at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
At the time of the inspection, conducted at approximately 11:50 am, the freezer located behind the walk-in refrigerator in the kitchen registered a temperature of 12 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The physical plant will be properly maintained at all times. This condition was immediately addressed by staff to ensure the health and safety of everyone at the site. Until the issue is resolved, this freezer will not be utilized. A work order was filed on 05/29/25 for maintenance to fully correct the issue. The anticipated completion date is 08/30/25. This issue will be monitored during regular health and safety checks, using the Freezer Temperature Log. The Program Director will review the health and safety reports at least monthly to ensure that this is being regularly monitored and that any issues noted are being reported to the Maintenance department via additional work orders. Any barriers to having this fully corrected will be brought to the attention of the Division Director and Deputy Director to address directly with the Maintenance department head. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the inspection, the fire extinguisher, located directly outside group room 601, was unable to be verified if it was annually inspected as the extinguisher was missing an inspection tag and there was no inspection date marked on the extinguisher itself.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This condition was immediately addressed by staff to ensure the health and safety of everyone at the site. Until the issue is resolved, this area will not be utilized. This fire extinguisher was replaced on 05/30/2025. This issue will be monitored during regular health and safety checks utilizing the fire run log sheet, and fire extinguishers will be inspected and initialed on a monthly basis. The Program Director will review the health and safety reports at least monthly to ensure that this is being regularly monitored and that any issues noted are being reported to the Maintenance department via additional work orders. Any barriers to having this fully corrected will be brought to the attention of the Division Director and Deputy Director to address directly with the Maintenance department head. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client # 4 was admitted on March 26, 2025 and was involuntarily terminated on April 18, 2025. There was no documentation, in the record, indicating the client received written notice of their involuntary termination from treatment at the project.
This is a repeat citation from the June 16, 2022, June 21, 2023, and May 17, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner. 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 7/1/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed. Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 7/1/25. The Clinical Supervisor will complete at least weekly reviews, 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 for 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. Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide the client an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.
Client # 4 was admitted on March 26, 2025 and was involuntarily terminated on April 18, 2025. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner. 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 7/1/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed. Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 7/1/25. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of unusual incidents, the facility failed to report to the Department an unusual incident, involving physical or sexual assault by staff or a client, within 3 business days.
There was documentation of a physical assault between clients, which occurred on October 14, 2024, but there was no documentation indicating the incident was reported to the Department. Additionally, there was a physical assault incident between clients, which occurred on September 12, 2024, but the documentation indicated the incident was reported to the Department on September 23, 2024.
This is a repeat citation from the May 17, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The report in question will be submitted by the Program Director via the Electronic Reporting System (ERS) no later than 6/18/25. All future reports will be submitted via by the Program Director 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 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 period as well confirmation of any required eternal reporting. Any which were not reported to DDAP will be reported immediately. The Division Director will report at least monthly to the Deputy Director regarding any issues in this area, identified barriers, or other areas requiring improvement. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in four of four applicable client records reviewed.
Client # 4 was admitted on March 26, 2025 and was discharged on April 18, 2025. There were no case consultation notes documented in the record at the time of inspection.
Client # 5 was admitted on January 28, 2025 and was discharged on April 14, 2025. There were no case consultation notes documented in the record at the time of inspection.
Client # 6 was admitted on August 2, 2024 and was discharged on August 30, 2025. There were no case consultation notes documented in the record at the time of inspection.
Client #7 was admitted on September 20, 2024 and was discharged on September 23, 2024. There were no case consultation notes documented in the record at the time of inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All documentation will be completed correctly and in a timely manner. 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 7/1/2025. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed. Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 7/1/2025. The Clinical Supervisor will complete at least weekly reviews, 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 for 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. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information in accordance with the facility policy and procedure manual, in three of four applicable client records reviewed.
The facility policy and procedure manual indicated a follow-up to the discharged client is to occur within one week of a referral or thirty days after discharge from the program.
Client # 4 was admitted on March 26, 2025 and was discharged on April 18, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted on January 28, 2025 and was discharged on April 14, 2025. The documentation of follow-up information in the record indicated follow-up was completed on May 27, 2025.
Client # 6 was admitted on August 2, 2024 and was discharged on August 30, 2025. The documentation of follow-up information in the record indicated follow-up was completed on January 19, 2025.
This is a repeat citation from the June 16, 2022, June 21, 2023, and May 17, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner. 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 7/1/2025. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed. Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 7/1/25. The Clinical Supervisor will complete at least weekly reviews, 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 for 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. Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation 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 personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring the documentation of follow-up information in the record was submitted and approved by the Department for the June 16, 2022, June 21, 2023 and May 17, 2024 annual licensing inspections. Not documenting follow-up information in the record was again found to be a deficiency in the May 29, 2025 annual licensing inspection.
A plan of correction for not completing an involuntary termination notification letter was submitted and approved by the Department for the June 16, 2022, June 21, 2023 and May 17, 2024 annual licensing inspections. Not completing an involuntary termination notification letter was again found to be a deficiency in the May 29, 2025 annual licensing inspection.
This finding was 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 |