INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 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, 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records and the facility policy and procedure manual, the facility failed to ensure they maintained a mechanism to collect feedback on completed training, per their policy, in three of three applicable personnel records reviewed.
The facility policy and procedure manual stated " Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos, or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/Clinical Supervisor. "
At the time of the inspection, there was no documentation of training feedback forms for external trainings completed in each applicable personnel record reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia will collect feedback on all completed trainings. This will be done utilizing our training management system. For training modules which are delivered via the training management system, this feedback will be entered by the employee at the conclusion of the training. For training modules which are delivered via any external sources, the feedback will be entered by the employee at the time that the certificate is uploaded to the training management system.
The employee's direct supervisor will review the training transcript at least quarterly to ensure that all completed training and feedback is reflected.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 June 2025 through April 2026 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
There was documentation indicating the presence of police and/or ambulance personnel on facility premises on December 29, 2025; however, 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.
The Program Director will review the DDAP regulation and Gaudenzia's policy and procedures regarding incident reporting with all staff by 6/15/26. The review will include incident types, how to report them internally, which incidents need to be reported to external agencies, who are responsible for reporting incidents to external agencies, and the timeframes for reporting.
All new staff are registered to complete Incident Reporting training upon hire as part of their individual training plan.
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 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 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 all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to document, as part of their intake process, a psychosocial evaluation of the client, in four of seven applicable client records reviewed.
The facility policy and procedure manual stated that the interpretive summary (psychosocial evaluation) of a client is to be completed within 30 days of admission.
Client # 2 was admitted on January 20, 2026 and was still active at the time of the inspection. There was no psychosocial evaluation documented in the client record at the time of the inspection.
Client # 3 was admitted on December 23, 2025 and was still active at the time of the inspection. There was no psychosocial evaluation documented in the client record at the time of the inspection.
Client # 5 was admitted on October 17, 2025 and was discharged on December 31, 2025. The psychosocial evaluation was due to be completed no later than November 17, 2025, per facility policy; however, the evaluation was not completed until December 2, 2025.
Client # 7 was admitted on January 13, 2026 and was discharged on February 23, 2026. There was no psychosocial evaluation documented in the client record at the time of the inspection.
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 to include the Psychosocial Evaluation.
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 5/29/26. 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 Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 5/22/26.
The Program Director will complete at least weekly 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 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 in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.93(a)(11) LICENSURE Client records
709.93. 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 and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow up information, in two of four applicable client records reviewed.
The policy and procedure manual stated that follow up information is to be documented within seven days of discharge if a client is referred to another treatment provider or thirty days of discharge for all other types of discharge.
Client # 5 was admitted on October 17, 2025 and was discharged on December 31, 2025. The follow up information was due to be completed no later than January 31, 2026; however, follow up information was not completed until March 24, 2026.
Client # 6 was admitted on September 26, 2025 and was discharged on January 7, 2026. The follow up information was due to be completed no later than February 7, 2026; however, follow up information was not completed until March 23, 2026.
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 to include Follow up information.
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 5/29/26. 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.
The Program Director will complete at least weekly 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 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 in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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