INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 13, 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. 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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709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.
Client #7 was admitted on March 11, 2026, and discharged on April 3, 2026. A release of information form to the emergency contact did not document the date, event or condition upon which the consent would expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An informed and voluntary consent from the client for the disclosure of information contained in the client record will be completed fully, correctly, and in a timely manner to include the date, event or condition upon which the consent will expire.
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 5/22/26. This training will include a detailed review of the standard regarding documenting the condition or date the consent will expire.
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 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 and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seven client records reviewed.
Client #2 was admitted on November 05, 2025, and discharged on January 03, 2026. A consent form signed and dated November 05, 2025, for a family member, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An informed and voluntary consent from the client for the disclosure of information contained in the client record will be completed fully, correctly, and in a timely manner to include documenting the client was offered a copy of the consent.
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 5/22/26. This training will include a detailed review of the standard regarding documenting offering the client a copy of the consent.
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 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 and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable record reviewed. Per the facility's policy and procedure manual, ASA/AMA discharges emergency contacts are to be called within twelve hours.
Client #1 was admitted on June 19, 2025 and was discharged Against Staff Advice (ASA) on September 20, 2025. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The individual's emergency contact will be notified within 12 hours of any client leaving against staff advice.
The Program Director will review with staff during the next all staff meeting the requirements for notifying and documenting emergency contacts within 12 hours of a client leaving ASA by 5/22/26.
The Program Director will review all ASA discharges to ensure the emergency contact, if a proper release is in place, has been notified and attempts made are documented in the client's chart. If no attempt has been made and documented, the Program Director will ensure the contact is made immediately either by themselves or the clinician.
The Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess the presence, timeliness and quality of each chart document.
The Gaudenzia Compliance Department will conduct a review of the plan of correction within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within 15 days of admission, in six of seven applicable records reviewed.
Client #1 was admitted on June 19, 2025 and was discharged on September 20, 2025. There was no documentation of case consultation information in the record.
Client #2 was admitted on November 05, 2025 and discharged January 03, 2026. The case consultation was not documented until December 05, 2025.
Client #3 was admitted on November 14, 2025 and was active at the time of the inspection. The case consultation information was not documented until January 06, 2026.
Client #4 was admitted on October 09, 2025 and was active at the time of the inspection. The case consultation was not documented until November 21, 2025.
Client #5 was admitted on December 17, 2025 and was active at the time of the inspection. The case consultation was not documented until January 31, 2026.
Client #6 was admitted on November 20, 2025, and was discharged on February 17, 2026. The case consultation was not documented until January 31, 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.
This requirement will be reviewed with all appropriate staff members in a documented in-service training to include Case Consults within the next two weeks, and no later than 5/22/26. 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 Clinical Supervisor 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 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 and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the citation within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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