INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2026 through June 4, 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. Withdrawal, Stabilization and Assessment Center (WSAC) 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of two applicable personnel records reviewed.
Employee #8 was hired as a recovery specialist on March 28, 2022. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than March 28, 2024. There was documentation of the timely completion of the HIV/AIDS training; however, there was no documentation indicating the TB/STD training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe.
The employee will complete the mandatory HIV/AIDS training no later than 7/30/26.
All staff members have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Supervisor will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion.
The Clinical Supervisor and Program Director will review the Individual Training Plans weekly for new hires, and at least quarterly for all staff. Staff who have upcoming training due dates within the next quarter will be reminded of this and the Supervisor will work with them to schedule training sessions prior to the due dates and will monitor to ensure full and timely completion.
If any issues are noted with staff failing to complete scheduled trainings, this will be specifically addressed with them in a documented supervision session with a clear plan to have all trainings completed.
If any issues are noted with unavailability of required training session opportunities, this will be addressed with the Division Director and the Regional Executive Director to assist in advocating with the training provider.
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. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, conducted on June 4, 2026, there was one portable space heater located in the second-floor nursing station area.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The space heaters were immediately removed from the program on 6/4/26.
An all-staff meeting will be held by 6/26/26 to review the regulation and Gaudenzia Policy and Procedure regarding space heaters not being used in the facility unless they are permanently affixed to a wall to ensure the safety of all clients and staff.
This issue will be monitored during regular health and safety checks. Any space heaters found will be immediately removed and the staff responsible will be reminded of the regulation and policy of no space heaters in the building unless they are permanently affixed to the wall
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 all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of seventeen client records reviewed.
Client #14 was admitted to the inpatient non-hospital detoxification activity on April 16, 2026 and discharged on April 18, 2026. A release of information form for an emergency contact was signed and dated by the client on April 16, 2026; however, there was no name of the person, agency, or organization to whom the disclosure was to be made included on the release 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 the name of the person, agency or organization to whom disclosure is made.
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 7/3/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Releases for any active client will be reviewed and updated as needed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 6/26/26.
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 all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed |