INITIAL COMMENTS
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This report is a result of an unannounced on-site inspection conducted on July 14, 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. A portable space heater was observed by DDAP staff in Counselor #1's office.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effectively immediately Program Director ensured that all space heaters were removed from the offices. RSP Supervisor will ensure that staff are aware as well as new hires that space heaters are not permitted in the facility.
Addendum: RSP supervisor will ensure that RSP staff are monitoring offices and areas throughout facility during their rounds to ensure that clients and/or staff are not bringing heaters into the facility. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to adhere to written procedures for the management of treatment/rehabilitation services for clients.
The facility's policy is to complete an American Society of Addiction Medicine (ASAM) assessment, on each patient, within five-days of admission.
Client #1was admitted on June 10, 2025, and was still active at the time of the inspection. An ASAM assessment was due to be completed no later than June 15, 2025; however, the initial ASAM for this client was completed on June 16, 2025.
This finding was reviewed with facility staff during the unannounced visit process
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Plan of Correction
Effective Immediately Program Director will continue to review clinical documentation and ensure that the clinical team are adhering to the workflow and submitting documentation according to the deadlines set forth by the agency. |