INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8, 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. West Chester 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary, and in good repair at all times for the safety and well-being of residents, employees and visitors.
At the time of the inspection, the female bedroom # 3 had excessive amounts of paint peeling off of the walls and the ceiling. Also, the male bedroom # 4 had a broken vent cover in the ceiling and paint that was peeling off the walls. Additionally, the male bedroom # 2 had a missing vent cover in the ceiling, which exposed the inner heating and air ductwork.
These findings were 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.
A work order was filed on 6/9/26 for maintenance to fully correct the issues. The anticipated completion date is 7/31/26.
This issue will be monitored during regular health and safety checks.
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 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.
Persons Responsible:
- Program Director
- Maintenance Department Staff
- Regional Executive Director
- Maintenance Department Head
- Director of Audits & Monitoring
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.
At the time of the inspection, the shared men's bathroom had a broken urinal that flooded the entire bathroom floor.
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 to ensure the health and safety of everyone at the site. The urinal has been fixed and flooding is no longer an issue as of 6/9/26.
This issue will be monitored during regular health and safety checks.
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 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.
Persons Responsible:
- Program Support Staff
- Program Director
- Maintenance Department Staff
- Regional Executive Director
- Maintenance Department Head
- Director of Audits & Monitoring
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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 the facility policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable client records reviewed.
Per the facility policy and procedure manual, the program will contact the participant's emergency contact within twelve hours when the participant leaves treatment against facility advice.
Client # 5 was admitted on July 16, 2025 and was discharged against facility advice on September 15, 2025. There was no attempted emergency contact notification documented in the record at the time of the inspection.
Client # 7 was admitted on May 29, 2025 and was discharged against facility advice on June 20, 2025. There was no attempted emergency contact notification documented in the record at the time of the inspection.
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 to include notifying the clients emergency contact if the client leaves against facility advice within 12 hours of the client leaving.
The Program Director will review with staff during the next all staff meeting the requirements for notifying and documenting emergency contacts within 12 hours of a client leaving ASA by 7/9/26.
Clinical Supervisor will audit discharge charts daily to include the notification of emergency contacts for clients that are ASA discharges. If the emergency contact has not been notified, the Clinical Supervisor will ensure it is completed that same day.
CQI Department will review a sample of discharge charts during semiannual audits.
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.
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.
Persons Responsible:
- Clinicians
- Clinical Supervisor
- Program Director
- Regional Clinical Director
- Regional Executive Director
- Quality Assurance Manager
- Director of Audits & Monitoring |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 maintain a complete client record on an individual, which is to include documentation of case consultation notes, in two of four applicable client records reviewed.
Client # 4 was admitted on August 16, 2025 and was discharged on October 6, 2025. There were no case consultation notes documented in the record as of the date of the inspection.
Client # 7 was admitted on May 29, 2025 and was discharged on June 20, 2025. There were no case consultation notes documented in the record as of the date of the inspection.
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 to include Case Consultation Notes.
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 7/9/26. 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 7/9/26.
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.
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 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 any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
Persons Responsible:
- Clinicians
- Clinical Supervisor
- Program Director
- Regional Clinical Director
- Regional Executive Director
- Quality Assurance Manager
- Director of Audits & Monitoring
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709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 the review of client records, the project failed to document a complete client record on an individual, which includes documentation of a discharge summary, in three of four applicable client records reviewed.
Client # 4 was admitted on August 16, 2025 and was discharged on October 6, 2025. A discharge summary was not documented in the record at the time of the inspection.
Client # 6 was admitted on June 16, 2025 and was discharged on September 9, 2025. A discharge summary was not documented in the record at the time of the inspection.
Client # 7 was admitted on May 29, 2025 and was discharged on June 20, 2025. A discharge summary was not documented in the record at the time of the inspection.
This is a repeat citation from the April 22, 2025 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All discharge 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 7/9/26. 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 discharged 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 7/9/26.
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.
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 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.
Persons Responsible:
- Clinicians
- Clinical Supervisor
- Program Director
- Regional Clinical Director
- Regional Executive Director
- Quality Assurance Manager
- Director of Audits & Monitoring
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