INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 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., Vantage 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 the facility failed to document a psychosocial evaluation in seven out of seven records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 13, 2025, April 23, 2024 and May 5, 2023 annual licensing inspection.
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Plan of Correction
At present, Vantage is temporarily closed, with an anticipated re-opening date of 9/1/26. As soon as Vantage is reopened, the following action steps will be implemented to ensure full compliance with all applicable regulations, however, in the event re-opening does not occur at that time, the action plan will be implemented immediately upon re-opening:
All documentation will be fully completed 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 session facilitated by the Regional Clinical Director within one week of hire. 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 if needed.
The CQI Manager will conduct chart reviews on a weekly basis to include confirmation of the presence of the Psychosocial Evaluation and will report these findings to program management each week for any necessary corrections.
Any issues noted in these reviews will be addressed by the Clinical Supervisor or Program Director with the clinician in a documented supervision session and will be corrected within 72 hours.
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. The Director of Audits & Monitoring will share the findings of this review with the Regional Clinical Director and Regional Executive Director in order to help coordinate support of the Program.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #1 was admitted on October 29, 2025 and was discharged on February 7, 2026. A comprehensive treatment plan was completed on November 3, 2025 and an update was due no later than December 3, 2025; however, it was completed on December 30, 2025. Additionally, the next update was due on January 30, 2026; however, none was completed prior to discharge.
Client #2 was admitted on January 2, 2026 and discharged on February 13, 2026. A comprehensive treatment plan was completed on January 9, 2026 and an update was due no later than February 9, 2026; however, none was completed prior to discharge.
Client #3 was admitted on December 24, 2025 and discharged on March 18, 2026. A treatment plan update was completed on February 1, 2026 and the next update was due on March 2, 2026; however, none was completed prior to discharge.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
At present, Vantage is temporarily closed, with an anticipated re-opening date of 9/1/26. As soon as Vantage is reopened, the following action steps will be implemented to ensure full compliance with all applicable regulations, however, in the event re-opening does not occur at that time, the action plan will be implemented immediately upon re-opening:
This requirement will be reviewed with all appropriate staff members in a documented in-service training session within one week of hire facilitated by the Regional Clinical Director. This training will include a detailed review of the standard, all relevant Gaudenzia policies, the specific areas of the clinical chart in which to document this information and how to request assistance when needed.
The CQI Manager will conduct chart reviews on a weekly basis to include confirmation of the presence of Treatment Plan Updates at least every 30 days and will report these findings to program management each week for any necessary corrections.
Any issues noted in these reviews will be addressed by the Clinical Supervisor or Program Director with the clinician in a documented supervision session and will be corrected within 72 hours.
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. The Director of Audits & Monitoring will share the findings of this review with the Regional Clinical Director and Regional Executive Director in order to help coordinate support of the Program.
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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 provide a complete client record, which is to include follow-up information in four out of seven records reviewed. The facility's policy and procedures manual states follow-ups must be completed within 30 days of discharge.
Client #2 was admitted on January 2, 2026 and discharged on February 13, 2026.
Client #3 was admitted on December 24, 2025 and discharged on March 18, 2026.
Client #4 was admitted on January 20, 2026 and discharged on March 18, 2026.
Client #7 was admitted on November 20, 2025 and discharged on December 19, 2025.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 13, 2025 and April 23, 2024 annual licensing inspection.
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Plan of Correction
At present, Vantage is temporarily closed, with an anticipated re-opening date of 9/1/26. As soon as Vantage is reopened, the following action steps will be implemented to ensure full compliance with all applicable regulations, however, in the event re-opening does not occur at that time, the action plan will be implemented immediately upon re-opening:
The Administrative Coordinator will run and review the "Detail of Discharges Report" in our EHR which indicates the date that the follow-up call is to be completed based on the date of discharge. The follow-up call will be documented utilizing the Follow Up Contact Note in the client's chart.
This requirement will be reviewed with the Administrative Coordinator for the facility in a documented in-service training session within one week of hire facilitated by the Regional Clinical Director. This training will include a detailed review of the standard, all relevant Gaudenzia policies, the specific areas of the clinical chart in which to document this information and how to request assistance when needed.
The CQI Manager will conduct chart reviews on a weekly basis to include confirmation of the presence of follow-up documentation and will report these findings to program management each week for any necessary corrections.
Any issues noted in these reviews will be addressed by the Clinical Supervisor or Program Director with the clinician in a documented supervision session and will be corrected within 72 hours.
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. The Director of Audits & Monitoring will share the findings of this review with the Regional Clinical Director and Regional Executive Director in order to help coordinate support of the Program.
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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 psychosocial evaluation was submitted and approved by the Department for the May 13, 2025, April 23, 2024 and May 5, 2023 annual licensing inspections. Psychosocial evaluations was again found to be a deficiency in the July 20, 2026 licensing inspection.
A plan of correction for follow-up information was submitted and approved by the Department for the May 13, 2025 and April 23, 2024 annual licensing inspections. Follow-up information was again found to be a deficiency in the July 20, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
At present, Vantage is temporarily closed, with an anticipated re-opening date of 9/1/26. As soon as Vantage is reopened, the following action steps will be implemented to ensure full compliance with all applicable regulations, however, in the event re-opening does not occur at that time, the action plan will be implemented immediately upon re-opening:
The Facility Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area of the Plan of Correction.
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 Program Director will report at least monthly to the Regional Clinical Director and Regional Executive Director regarding any outstanding items, to review and identify barriers to the implementation of any outstanding action item. Any barriers noted will be addressed as appropriate.
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 to full compliance.
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. The Director of Audits & Monitoring will share the findings of this review with the Regional Clinical Director and Regional Executive Director in order to help coordinate support of the Program.
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