INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ellen O ' Brien Gaiser Center 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 applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of three staff records.
Staff #5 was hired as a support staff member on June 3, 2024 and was still in this position at the time of the inspection. The HIV/AIDS training was to be completed no later than June 3, 2026; however, this was not completed until July 15, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Manager will implement a tracking system accessible to all staff that will warn them 90 days in advance of training deadlines. HR Manager will also track all staff training with deadlines in our SharePoint system, where all staff can monitor with HR and their supervisor. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of applicable client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in two of two records.
The facility's inpatient non-hospital residential policy and procedure manual states the client's emergency contact will be notified within twenty-four hours of the client's decision to leave against facility advice, providing there is consent given in writing for the facility to contact the emergency contact.
Client #6 was admitted on November 6, 2025 and was discharged on December 5, 2025. There was a consent for the emergency contact in client #6 ' s record. There was no documentation that the emergency contact was notified.
Client #7 was admitted on January 9, 2026 and was discharged on January 14, 2026. There was a consent for the emergency contact in client #7 ' s record. There was no documentation that the emergency contact was notified.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 9, 2025, and July 10, 2024 annual licensing inspections.
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Plan of Correction
Clinical Director has implemented AFA to be shared at morning staffing every day on the shift change sheet. AFAs are also listed at the bottom of the census report now for all staff to monitor. Clinical Director/Supervisor or Project Director will go into Chart within 24 hours of AFA notification to ensure that EC has been notified. Progressive disciplinary action will follow for the counselor of record if not. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of three records. The policy and procedure manual indicates follow-up contact must be made within seven days of discharge.
Client #5 was admitted on February 24, 2026 and was discharged on March 22, 2026. The follow-up contact was due to be completed no later than March 29, 2026; however, this was not completed until April 1, 2026.
Client #6 was admitted on November 6, 2025 and was discharged on December 5, 2025. The follow-up contact was due to be completed no later than December 12, 2025; however, this was not completed until December 15, 2025.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9, 2025, and July 10, 2024 annual licensing inspections.
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Plan of Correction
The Clinical Director has implemented 7-day follow-up calls for the daily census, and they are also included in the shift-change staffing report every day. These are not removed until the call has been made and documented. Clinical Director/Supervisor/Project Director will go into the charts of the names on the census by day 7 to ensure that the call has been made and documented. Progressive disciplinary action will be enforced for those counselors not complying. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for contacting a client's emergency contact when they leave the facility against medical advice was submitted and approved by the Department for the July 9, 2025 and July 10, 2024 annual licensing inspections. Contacting a client's emergency contact when they leave the facility against medical advice was again found to be a deficiency in the June 15, 2026 annual licensing inspection.
A plan of correction for follow-up contact was submitted and approved by the Department for the July 9, 2025 and July 10, 2024 annual licensing inspections. Follow-up contact was again found to be a deficiency in the June 15, 2026 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will post the previously approved plans of correction for these deficiencies into the census as well, to ensure that the whole team can see the actions taken. The clinical director will continue to review these previously approved plans of correction with the clinical staff during staff meetings to ensure that they are taking the current actions and are continuously aware of what steps they need to take to comply with the approved plans of correction. |