INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 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 West Shore 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) 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 client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.Client #7 was admitted to the outpatient level of care on September 15, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated September 15, 2025, for a funding source, but did not include the signature of the client. The facility confirmed disclosure had occurred.This 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.
This requirement will be reviewed with all appropriate staff members in a documented in-service training no later than 4/30/26. 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 and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 4/30/26.
The Program Director will complete at least weekly reviews, the Regional Clinical 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 Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document that a comprehensive treatment plan was developed with the client and within guidelines established by the facility's policy and procedures manual in three out of seven records reviewed. The facility's policy and procedures manual states that the comprehensive treatment plan is completed within thirty days of admission. Client #1 was admitted on August 11, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 27, 2025; however, there is no documentation that the comprehensive treatment plan was completed with the client.Client #3 was admitted on September 17, 2025 and discharged on February 18, 2026. A comprehensive treatment plan was completed on October 06, 2025; however, there is no documentation that the comprehensive treatment plan was completed with the client. Client #4 was admitted on September 03, 2025 and discharged on March 09, 2026. A comprehensive treatment plan was completed on September 19, 2025; however, there is no documentation that the comprehensive treatment plan was completed with the client. Client #6 was admitted on September 17, 2025 and was still active at the time of inspection. A comprehensive treatment plan was completed on October 13, 2025; however, there is no documentation that the comprehensive treatment plan completed with the client. Client #7 was admitted on September 15, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on September 20, 2025; however, there is no documentation that comprehensive treatment plan was completed with the client. This is a repeat citation from March 25, 2025 licensing inspection. These findings were reviewed with facility staff during licensing process.
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Plan of Correction
All Treatment Plans will be completed correctly and in a timely manner. If a client is not available or is a no-show for the session during which the Treatment Plan is scheduled to be completed, this will be documented in a note to chart.
The Comprehensive Treatment Plan will be created with the client at the next session.
This requirement will be reviewed with all appropriate staff members in a documented in-service training no later than 4/30/26. 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 Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 4/30/26.
The Program Director will complete at least weekly reviews, the Regional Clinical 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 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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