INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 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. 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.
Client #2 was admitted on November 07, 2025, and was still active at the time
of the inspection. There was documentation that information was disclosed to county probation on February 27, 2026; however, the record did not
contain documentation of an informed and voluntary consent from the client
for the disclosure of information. Facility confirmed disclosure.
The finding was reviewed with facility staff during the licensing inspection.
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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. A voluntary consent will be completed before releasing information regarding a client when required.
This requirement will be reviewed by the Clinical Supervisor with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. 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.
Proper release for probation will be obtained for Client #2 by 5/29/2026 at the least or during the next scheduled session. No further communication will occur with county probation until release is secured.
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.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven records reviewed.
Client #3 was admitted on August 25, 2025 and was still active at the time of the inspection. A treatment plan update was completed on January 15, 2026 and an update was due no later than March 15, 2026; however, one was not completed until March 19, 2026.
Client #4 was admitted on September 29, 2025 and was still active at the time of the inspection. A treatment plan update was completed on January 5, 2026 and an update was due no later than March 5, 2026; however, it was not completed until March 19, 2026.
Client #5 was admitted on June 30, 2025 and was discharged on March 11, 2026. A treatment plan update was completed on December 01, 2025 and the next update was due no later than February 1, 2026; however, one was not completed until February 11, 2026.
Client #6 was admitted on September 15, 2025 and was discharged on May 3, 2026. A treatment plan update was completed on December 17, 2025 and an update was due no later than February 17, 2026; however, it was not completed until February 25, 2026.
Client #7 was admitted on July 30, 2025 and was discharged on April 08, 2026. A treatment plan update was completed on October 29, 2025 and an update was due no later than December 29, 2025; however, it was not completed until February 18, 2026.
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. All Treatment Plan updates will be completed per Gaudenzia's policy.
If a client is not available or is a no-show for the session during which the Treatment Plan is scheduled to be completed/updated, this will be documented in a note to chart. Prior to receiving any additional services, the Treatment Plan will be updated with the client.
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 5/29/26. 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.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full |
709.93(a)(8) LICENSURE Client records
709.93. 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 document a case consultation within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #1 was admitted on September 15, 2025 and was still active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #3 was admitted on admitted on August 25, 2025 and was still active at the time of the inspection. A case consultation was due no later than November 25, 2025; however, it was not completed until December 03, 2025.
Client #4 was admitted on September 29, 2025 and was still active at the time of the inspection. A case consultation was due no later than December 29, 2025; however, it was not completed until February 09, 2025.
Client #6 was admitted on September 15, 2025 and discharged against staff advice on April 03, 2026. A case consultation was due no later than December 15, 2025; however, it was not completed until January 28, 2026.
Client #7 was admitted on July 30, 2025 and successfully discharged on April 08, 2026. A case consultation was due no later than October 30, 2025; however, one was not completed until February 04, 2026.
This is a repeat citation from April 11, 2025 annual licensing inspection.
These findings were reviewed by 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 completing Case Consultation notes according to Gaudenzia's 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 5/29/26. 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 Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 5/22/26.
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.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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