INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2025 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection, the facility failed to keep cold food at or below 40 hot food at or above 140 and frozen food at or below 0
At the time of the inspection, conducted on May 21, 2025 at approximately 10:30 AM, the freezer temperature was registered at a temperature of 10 Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The physical plant 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 freezer will not be utilized. A work order was filed on 5/29/25 for maintenance to fully correct the issue. The anticipated completion date is 8/29/25. This issue will be monitored during regular health and safety checks, using the Freezer Temperature Log. 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 Deputy Director to address directly with the Maintenance department head.
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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 a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of two applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 3 was admitted to the inpatient non-hospital detoxification activity on March 17, 2025 and was discharged against medical advice on March 19, 2025; however, there was no documentation in the record indicating the emergency contact was notified of the client's discharge.
This is a repeat citation from the May 14, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The emergency contact will be notified within 12hours for all clients who choose to leave ASA, as specified in Gaudenzia policy. 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 6/30/25. 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 6/30/25. 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, timelines 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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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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, including the reason for termination, in one of one applicable client records reviewed.
Client # 14 was admitted to the inpatient non-hospital activity on January 23, 2025 and was administratively discharged on January 27, 2025. There was no documentation in the record indicating the client was provided written notification of the facility's decision to involuntarily terminate 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. 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 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which 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 than6/30/25. 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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake process, a psychosocial evaluation of the client in two of six applicable client records reviewed.
The facility policy and procedure manual states that a psychosocial evaluation is to be completed within 72 hours of admission for a client receiving treatment in the inpatient non-hospital detoxification activity.
Client #1 was admitted to the inpatient non-hospital detoxification activity on August 16, 2024 and was discharged on August 21, 2024. There was no psychosocial evaluation documented in the client record at the time of the inspection.
Client #4 was admitted to the inpatient non-hospital detoxification activity on September 5, 2024 and was discharged on September 9, 2024. The psychosocial evaluation was due to be completed no later than September 8, 2025; however, it was not completed until September 9, 2024.
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 within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required time frames; 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 6/30/25. The Clinical Supervisor will complete at least weekly reviews, 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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time. The Program Director will complete. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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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 follow-up information, in three of seven applicable client records reviewed.
Client #1 was admitted to the inpatient non-hospital detoxification activity on August 16, 2024 and was discharged on August 21, 2024. There was no follow up information documented in the record as of the date of the inspection.
Client # 3 was admitted to the inpatient non-hospital detoxification activity on March 17, 2025 and was discharged on March 19, 2025. There was no follow up information documented in the record as of the date of the inspection.
Client # 6 was admitted to the inpatient non-hospital detoxification activity on January 13, 2025 and was discharged on January 16, 2025. There was no follow up information documented in the record as of the date of the inspection.
This is a repeat citation from the June 14, 2022, June 20, 2023 and May 14, 2024 annual licensing renewal inspections.
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 within the next two weeks, and no later than 6/30/25. This training will include a detailed review of the standard; all relevant Gaudenzia policies the Gaudenzia workflow document which specifies the required time frames 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 6/30/25.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 within48 hours. Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client # 8 was admitted to the inpatient non-hospital activity on March 28, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 31, 2025; however, the plan did not include the proposed type of support services.
Client # 10 was admitted to the inpatient non-hospital activity on April 23, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 30, 2025; however, the plan did not include the proposed type of support services.
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 within the next two weeks, and no later than 6/30/25. 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 6/30/25.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 director in regular supervision sessions, and any barriers to implementation addressed at that time. |
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 a review of client records, the facility failed to assure counseling services were being provided to the client according to the individual treatment and rehabilitation plan in three of four applicable client records reviewed.
Client # 8 was admitted to the inpatient non-hospital activity on March 28, 2025 and was still active at the time of the inspection. The individual treatment plan, completed on April 15, 2025, indicated the client was to receive one individual therapy session per week. There was no individual therapy session documented on the client's record of service and progress notes during the week of April 27, 2025 through May 3, 2025
Client # 9 was admitted to the inpatient non-hospital activity on April 18, 2025 and was still active at the time of the inspection. The individual treatment plan, completed on April 25, 2024, indicated the client was to receive one individual therapy session per week. There was no individual therapy session documented on the client's record of service and progress notes during the week of April 27, 2025 through May 3, 2025
Client # 11 was admitted to the inpatient non-hospital activity on September 9, 2024 and was discharged on October 4, 2024. The individual treatment plan, completed on September 12, 2024, indicated the client was to receive one individual therapy session per week. There was no individual therapy sessions documented on the client's record of service and progress notes during the weeks of September 22, 2024 through September 28, 2024.
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 ocumented in-service training within the next two weeks, and no later than 6/30/25. 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 6/30/25.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 within48 hours.Progress in this areawill be monitored bythe Division Directorand Deputy Directorin regular supervisionsessions, and anybarriers toimplementationaddressed at that time.Plan ofCorrection:
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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 client records, the facility failed to comply with plans of corrections that were approved by the Department.
A plan of correction for not documenting follow-up information in the client record was submitted and approved by the Department for the June 14, 2022, June 20, 2023, and May 14, 2024, annual licensing inspections. Not documenting follow-up information in the client record was again found to be a deficiency in the May 20, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area above. 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 bead dressed as appropriate. The Division Director will report at least monthly to the Deputy Director regarding any outstanding items, identified barriers, or other areas requiring improvement. Any areas noted as not meeting the requirements listed above will be addressed with the Program Director in a documented supervision session note detailing any additional required actions to be taken to bring the program into full compliance. |