INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 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 - New Destiny 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors and lead counselors, who have not functioned for 2 years as a supervisor in the provision of clinical services, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on January 13, 2025 and did not have 2 years of clinical supervision experience prior to being hired at this facility. The clinical supervision core curriculum training was not completed until September 22, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
If a Clinical Supervisor or lead counselor, who has not functioned for 2 years as a supervisor in the provision of clinical services is hired, they will have the Clinical Supervision training added to their Individual Training Plan to be completed within 6 months.
If the training is not available or is cancelled, all efforts to schedule and complete the training will be documented to include any email notifications of the training not being available or cancelled.
The Program Director will review the Individual Training Plan with the Clinical Supervisor or Lead Counselor during monthly supervision until the training is completed.
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.
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report, the facility failed to ensure the inpatient nonhospital treatment and rehabilitation activity did not exceed the adult client to counselor ratio of one full-time equivalent (FTE) counselor for every twelve clients.
The facility's overall client to counselor FTE ratio is determined by dividing the total number of hours all counselors devote to their clients by the facility's work week. Then, the overall ratio is determined by dividing the facility's total number of active clients by the FTE.
The overall calculation for the facility was as follows: 40 (devoted client hours) divided by 40 (facility's workweek hours) = 1 (this is the FTE). The number of reported active clients at the time of the inspection was 18; therefore, the remaining calculation is 18 divided by 1 = 18, which equals to a client to FTE counselor ratio of 18/1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The FTE maximum client/staff and client/counselor ration will be maintained at all times. It will be the Program Director's responsibility to ensure the staff to client ratio is properly maintained.
In the future, for each potential admission, the Program Director will review the clinical staffing, hours worked, and client census to ensure the required staff to client ratio is maintained. If the staffing does not support the required ratio, the client will be referred to and helped to be admitted to another facility of their choice.
In addition, when staffing changes occur, the Program Director will ensure the staff to client ratio remain in compliance based on the number of available clinical staff and hours worked.
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. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed to maintain all structures, fences, and playground equipment on the grounds of the facility so as to be free from any danger to health and safety.
At the time of the inspection, the wooden picnic table and bench, located in the children's playground equipment area, had broken sections, sharp splintered wood, and exposed nails.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bench that was in disrepair was removed from the facility on May 6, 2026.
The physical plant will be properly maintained at all times.
The Program Director will review the health and safety reports at least monthly to ensure that this is being regularly monitored and that any issues noted are being reported to the Maintenance department via additional work orders.
Any barriers to having this fully corrected will be brought to the attention of the Division Director and Regional Executive Director to address directly with the Maintenance department head.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client # 2 was admitted on January 27, 2026 and was still active at time of inspection. The treatment and rehabilitation plan was signed and dated March 31, 2026 and indicated the client was to receive one individual session per week. There was no documentation in the record of any individual sessions being provided to the client during the week of April 19, 2026.
Client # 3 was admitted on February 11, 2026 and was still active at time of inspection. The treatment and rehabilitation plan was signed and dated April 16, 2026 and indicated the client was to receive one individual session per week. There was no documentation in the record of any individual sessions being provided to the client during the week of April 19, 2026.
Client # 4 was admitted on September 15, 2025 and was discharged on December 19, 2025. The treatment and rehabilitation plan was signed and dated November 18, 2025 and indicated the client was to receive one individual session per week. There was no documentation in the record of any individual sessions being provided to the client during the week of November 30, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment services will be delivered in accordance with all relevant regulations and the Treatment Plan.
The Scheduling Calendar in our EHR system will be utilized in order to ensure that this occurs as required. This will be monitored by the Program Director on a weekly basis and any issues noted will be immediately brought to the attention of the clinician for remedy.
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 6/15/ 2026. 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 complete at least weekly reviews, the Program Director will complete at least monthly 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 for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
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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 maintain a complete client record on an individual, which is to include documentation of case consultation notes, in one of three applicable client records reviewed.
Client # 7 was admitted on August 12, 2025 and was discharged on December 1, 2025. There were no case consultation notes documented in the record at the time of the inspection.
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 Case Consultation Notes.
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; 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 complete at least weekly reviews, the Program Director will complete at least monthly 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 for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or 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.
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