INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 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.- Integrity 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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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection on March 14, 2025, the facility failed to ensure that the stairways, hallways and exits from rooms and from the residential facility are unobstructed. The third floor exit door leading to the fire escape would not open during the physical plant inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The director immediately contacted the Manager of Maintenance on 3/15/25 for removal of the weatherization strip on the third-floor exit door leading to the fire escape. The maintenance crew was dispatched immediately to remove the weatherization strip. The exit is now fully functional. Exit doors will be tested during emergency drills. Drills will be documented using the standard grid. Any issues noted will be brought to the immediate attention of the Program Director and corrected. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of seven records reviewed.
Client #4 was admitted on May 9, 2024 and discharged on August 3, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #5 was admitted on June 26, 2024 and discharged on September 26, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This is a repeat citation from the April 15, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will ensure that all consents are signed by the staff and client upon admission. The Director reviewed in the clinical team meeting on 3/24/25 the importance of clinicians obtaining signatures for all consents as well as which forms to use and all areas to be completed. The Director will review each clinician's admission documentation to ensure that the consents are completed and signed. The Director will conduct at least monthly reviews of charts. Any issues noted will be brought to the attention of the clinician in a documented supervision session note and corrected within 48 hours. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection on March 14, 2025, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was eye drops in stored with the oral medication in the medication cart.
This is a repeat citation from the April 15, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will ensure the weekly inspection of medication storage areas and med/cart is completed and documented by trained staff in compliance with State and Federal laws, including verification of what is inspected, who completed the inspection, separate storage of oral medication and eyedrops. This was reviewed with all staff in the clinical team meeting on 3/24/25. A copy of all inspection reports will be maintained by the Administrative Coordinator. Monitoring of continued conformance will be conducted by the Director. Any issues noted will be corrected immediately and brought to the attention of the staff responsible in a documented supervision session note. |
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 the review of client records, the facility failed to document a psychosocial evaluation in four out of seven records reviewed. The facility ' s policy and procedures manual states that the psychosocial is due within five days of admission.
Client #1 was admitted on December 5, 2024 and was still active at the time of the inspection. A psychosocial evaluation was due no later than December 10, 2025; however, it was completed on December 16, 2025.
Client #2 was admitted on January 10, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than January 15, 2025; however, it was completed on January 24, 2025.
Client #5 was admitted on June 26, 2024 and discharged on September 26, 2024. A psychosocial evaluation was due no later than July 1, 2024; however, it was completed on July 5, 2024.
Client #6 was admitted on September 3, 2024 and discharged on January 3, 2025. A psychosocial evaluation was due no later than September 8, 2024; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will ensure that the clinicians have completed the Biopsychosocial Evaluation according to the Workflow. This was reviewed with all staff in the clinical team meeting on 3/24/25. The Director will conduct at least monthly reviews of charts. Any issues noted will be brought to the attention of the clinician in a documented supervision session note and corrected within 48 hours. |
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 four out of six client records reviewed.
Client #1 was admitted on December 5, 2024 and was still active at the time of the inspection. A treatment plan was completed on February 6, 2025 and the next update was due no later than March 6, 2025; however, it was completed on March 8, 2025.
Client #2 was admitted on January 10, 2025 and was still active at the time of the inspection. A treatment plan was completed on January 15, 2025 and the next update was due no later than February 15, 2025; however, it was completed on February 20, 2025.
Client #4 was admitted on May 9, 2024 and discharged on August 3, 2024. A treatment plan was completed on June 6, 2024 and the next update was due no later than July 6, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on September 3, 2024 and was discharged on January 3, 2025. A treatment plan was completed on October 2, 2024 and the next update was due no later than November 2, 2024; however, it was completed on November 13, 2024.
This is a repeat citation from the April 15, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will continue to send out reminders of treatment plan update due dates 24 hours in advance. This was reviewed with all staff in the clinical team meeting on 3/24/25. The Director will conduct at least monthly reviews of charts. Any issues noted will be brought to the attention of the clinician in a documented supervision session note and corrected within 48 hours. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in three out of four applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #4 was admitted May 9, 2024 and was discharged on August 3, 2024. A discharge summary was due no later than August 10, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on June 26, 2024 and discharged on September 26, 2024. A discharge summary was due no later than October 3, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on September 3, 2024 and discharged on January 3, 2025. A discharge summary was due no later than January 10, 2025. There is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will ensure that all client records are complete, including all discharge summaries. The discharge summaries will be completed within seven days of the discharge date. The Director will send out daily reminders of what is due by the close of business. This was reviewed with all staff in the clinical team meeting on 3/24/25. The Director will conduct at least monthly reviews of charts. Any issues noted will be brought to the attention of the clinician in a documented supervision session note and corrected within 48 hours. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record including information relative to the client's involvement with the project, to include verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in three of seven client records reviewed.
Client #1 was admitted on December 5, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plans dated December 12, 2024, January 9, 2025, February 6, 2025 and March 8, 2025 did not include verification that work done by the client at the project is an integral part of treatment; however, the record contained evidence that the client did work at the facility.
Client # 2 was admitted on January 10, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plans dated January 15, 2025, February 20, 2025 and March 7, 2025 did not include verification that work done by the client at the project is an integral part of treatment; however, the record contained evidence that the client did work at the facility.
Client #7 was admitted on June 28, 2024 and discharged on August 19, 2024. The individual treatment and rehabilitation plan dated July 28, 2024, did not include verification that work done by the client at the project is an integral part of treatment; however, the record contained evidence that the client did work at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will ensure that any work to be done by the clients will be included as an integral part of treatment as Activities of Daily Living in the goal section of the Treatment Plan. The Director reviewed the importance of documenting these goals in the treatment plans during the clinical team meeting on 3/24/25. The Director will monitor all client's charts to make sure this goal is included. The Director will conduct at least monthly reviews of charts. Any issues noted will be brought to the attention of the clinician in a documented supervision session note and corrected within 48 hours. |