INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 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. Broad St. 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 one of one 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."
Employee # 2 was hired as the facility director on November 21, 2022. There was no training feedback form documented, in the personnel record, for an external training which was taken during the reviewed 2025 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia will collect feedback on all trainings utilizing our educational training management system. For training modules which are delivered via any external sources, the feedback will be entered by the employee at the time the certificate is uploaded to our educational training 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 |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to maintain slip-resistant surfaces in all bathtubs and showers.
During the inspection, conducted on April 28, 2026 at approximately 12:45 PM, there were no non-slip surfaces in all of the showers within the facility. Additionally, there were missing tiles on the shower floor in the female bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The physical will be properly maintained at all times. This condition was immediately addressed by staff to ensure the health and safety of everyone at the site. Until the issue is resolved, this area will not be utilized. A work order was filed on 5/7/2026 for maintenance to fully correct issue of missing tiles and was completed on 5/14/2026.
A purchase order was placed on 5/7/2026 for slip-resistant shower mats for all showers.
These issues will be monitored during regular health and safety checks. The program director will review health and safety reports at least monthly to that theses areas are being regularly monitored and any issues are being reported to maintenence via work orders. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on an administrative review of the July 2025 through March 2026 fire drill logs, the facility failed to document the amount of time it took for evacuation, the exit route used and the number of persons in the facility at the time of the drill on their monthly fire drill logs.
At the time of the inspection, the log for the March 2026 fire drill did not include the amount of time it took for evacuation. Also, the logs for the August 2025 and October 2025 fire drills did not include the exit route used. Additionally, the log for the February 2026 fire drill did not include the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 5/29/2026. This training will include a detailed review of the standard and all relevant Gaudenzia policies. The program director will review each fire drill held and documented to ensure all of the necessary components, including the time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill, are included in the fire drill log. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on an administrative review of the July 2025 through March 2026 fire drill logs, the facility failed to prepare alternate routes to be used during fire drills.
At the time of the inspection, every fire drill log completed during the reviewed period had the North Tower listed as the sole exit route used. There was no other documentation indicating alternate fire drill exit routes were used during the entire reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
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 5/29/2026. This training will include a detailed review of the standard and all relevant Gaudenzia policies. The program director will review each fire drill held and documented to ensure all of the necessary components, including using alternative routes during the fire drills are included in the fire drill log. Program director will review fire drill logs at least quarterly to ensure compliance is ongoing. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on an administrative review of the July 2025 through March 2026 fire drill logs, the facility failed to ensure a fire alarm or smoke detector was set off during each fire drill.
At the time of the inspection, there was no documentation indicating a fire alarm or smoke detector was set off during the September 2025 through January 2026 fire drills.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
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 5/29/2026. This training will include a detailed review of the standard and all relevant Gaudenzia policies. The program director will review each fire drill held and documented to ensure all of the necessary components, including the use of Fire alarms and smoke detectors for each drill, are included in the fire drill logs. Program director will review logs at least quarterly to ensure compliance. |
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 review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The facility policy and procedure related to against medical advice discharges of a client is that the emergency contact will be called within twelve hours of the client leaving treatment.
Client # 5 was admitted on December 4, 2025 and was discharged against medical advice on December 26, 2025. There was documentation in the client chart that the emergency contact was not notified of the client's discharge until December 29, 2026.
This is a repeat citation from the May 21, 2025 and May 15, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will review with staff during the next staff meeting the requirements for notifying emergency contacts within 12 hours of a client leaving ASA by 5/29/2026.
Clinical supervisor will review all ASA discharges to include whether the emergency contact is notified, or attempts were made to notify them within 12 hours of an ASA if an release of information signed by the client has been completed. If the required documentation is not found a note to chart will be written to include whether there was an appropriate release of information or not for anyone who leaves ASA. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is also to include the reason for termination, in one of one applicable client records reviewed.
Client # 4 was admitted on November 19, 2025 and was administratively discharged on December 3, 2025. There was no documentation in the record indicating if the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was 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 notifying the client in writing the reason for an involuntary termination. The requirement will be reviewed with all appropriate staff members in a documented in service training within 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 clinical supervisor will review all clients' chart who are involuntary terminated to ensure client was notified in writing the reason for the involuntary termination. The program director will conduct monthly reviews of clients who are involuntarily terminated from treatment. |
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, as part of their intake and admission process, in four of seven client records reviewed.
The facility policy and procedure manual stated that the psychosocial evaluation is to be completed within 5 days of admission.
Client # 1 was admitted on March 18, 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 # 2 was admitted on March 26, 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 March 26, 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 # 6 was admitted on June 16, 2025 and was discharged on July 22, 2025. The psychosocial evaluation was due to be completed no later than June 21, 2025; however, it was not completed until July 3, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be 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 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 if needed.
Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the clinical supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 5/29/26.
The clinical supervisor will complete at least weekly reviews, the program director will complete at least monthly reviews to ensure compliance.
Any issues noted will be reviewed by clinical supervisor or program director with the clinician in a documented supervision session. |
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 maintain a complete client record, which is to include the documentation of a discharge summary, in two of four applicable records reviewed.
Client # 4 was admitted on November 19, 2025 and was discharged on December 3, 2025. There was no discharge summary documented in the record as of the date of the inspection.
Client # 5 was admitted on December 4, 2025 and was discharged on December 26, 2025. There was no discharge summary documented in the record as of the date of the inspection.
This is a repeat citation from the May 21, 2025 and May 15, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All discharge documentation will be completed correctly and in a timely manner to include the discharge summary.
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 chart in which to document this information, and how to request assistance when needed. |
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 personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to notify an emergency contact, within twelve hours, when a client was discharged against medical advice was submitted and approved by the Department for the May 15, 2024 and May 21, 2025 annual licensing inspections. Failing to notify an emergency contact, within twelve hours, when a client was discharged against medical advice was again found to be a deficiency in the April 28, 2026 annual licensing inspection.
A plan of correction for failing to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, was submitted and approved by the Department for the May 15, 2024 and May 21, 2025 annual licensing inspections. Failing to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, was again found to be a deficiency in the April 28, 2026 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 Division Director will meet with the program director at least monthly in documented supervision sessions to review and identify barriers to the implementation of each 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 note detailing required actions to be taken to bring the program into full compliance. |