INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 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. 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, the facility failed to ensure that one employee received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of one records.
Staff #6 was hired as a counselor on April 22, 2024 and still employed. Communicable disease trainings were due to be completed no later than April 22, 2025 but not completed at the time of inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will complete all DDAP required trainings within the first year of employment.
Staff member #6 completed the DDAP HIV/AIDs training on 8/22/25.
All staff have a training plan generated upon hire to include all DDAP required trainings.
All staff training plans will be reviewed at least quarterly with the Clinical Director/Supervisor to ensure that trainings are scheduled and completed with enough lead time to be in compliance with all DDAP regulations. Any issues noted will be addressed in a documented supervision session, and trainings will be scheduled immediately. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records in the partial hospitalization level of care, the facility failed to review and update treatment and rehabilitation plans within 30 days in four of five client records.
Client #8 was admitted on May 22, 2025 and discharged on July 24, 2025. A treatment plan was completed on June 20, 2025 and an update was due by July 20, 2025 but not completed prior to discharge.
Client #9 was admitted on February 10, 2025 and discharged on May 16, 2025. A treatment plan was completed on March 20, 2025 and an update was due by April 19, 2025 but not completed until April 22, 2025.
Client #10 was admitted on March 6, 2025 and discharged on May 15, 2025. A treatment plan was completed on April 2, 2025 and an update was due by May 2, 2025 but not completed until May 9, 2025.
Client #13 was admitted on May 27, 2025 and discharged on August 4, 2025. A treatment plan was completed on June 27, 2025 and an update was due by July 27, 2025 but not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans updates will be completed and documented within required timeframes.
The Clinical Director reviewed policies and expectations with all staff regarding treatment plan time frames on 9/11/2025.
Staff will utilize the treatment plan tracker tool in our EHR to conduct weekly checks to ensure that all treatment plans are completed within required time frames. The Clinical Director will send treatment plan reports weekly to all clinicians as a reminder. If a Clinician is out of compliance this will be discussed in a documented clinical supervision session, and a Performance Improvement Plan will be initiated. Progress will be monitored via monthly chart reviews. The Clinical Director will review progress during monthly supervision sessions. Any required corrections will be completed within 72 hours. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of client records in the partial hospitalization level of care, the facility failed to document case consultations in one of one applicable record.
According to the facilities policy and procedure, a case consultation must be completed 90 days following admission.
Client #9 admitted on February 10, 2025 and discharged on May 16, 2025. A case consultation was due by May 11, 2025 but not completed prior to discharge.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All Case Consultations will be completed and documented within required timeframes.
The Clinical Director reviewed policies and expectations with all staff regarding case consultations time frames on 9/11/2025.
Administrative staff will run a report to identify needed case consultations to be reviewed bi-weekly in staff meetings.
If a Clinician is out of compliance this will be discussed in a documented clinical supervision session, and a Performance Improvement Plan will be initiated. Progress will be monitored via monthly chart reviews. The Clinical Director will review progress during monthly supervision sessions. Any required corrections will be completed within 72 hours. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on a review of client records in the partial hospitalization level of care, the facility failed to document a discharge summary in four of seven records reviewed.
According to the facilities policy and procedure, a discharge summary must be completed within 7 days of all discharges.
The following client records did not include a discharge summary:
Client #9 admitted on February 10, 2025 and discharged on May 16, 2025.
Client #10 admitted on March 6, 2025 and discharged on May 15, 2025.
Client #11 admitted on February 13, 2025 and discharged on April 11, 2025.
Client #14 admitted on April 21, 2025 and discharged on June 16, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All Discharge Summaries will be completed within required timeframes.
The Clinical Director reviewed policies and expectations with all staff regarding Discharge Summaries on 9/11/2025.
The Clinical Director will run the discharge report weekly to be reviewed in staff meetings.
If a Clinician is out of compliance this will be discussed in a documented clinical supervision session, and a Performance Improvement Plan will be initiated. Progress will be monitored via weekly spot checks and monthly chart reviews. The Clinical Director will review progress during monthly supervision sessions. Any required corrections will be completed within 72 hours. |