INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.
Client #6 was admitted on June 13, 2024, and was discharged on November 6, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #7 was admitted on November 7, 2024, and was discharged on March 25, 2025. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On June 18th, 2025, during the weekly clinical meeting with counselors, the Clinical Supervisor will review confidentiality regulations related to the project shall obtain informed and voluntary consent from the client for the disclosure of information contained in the client record, which includes the funding source.
Ongoing, during monthly chart audits, Clinical Supervisor will review the releases that are in the charts for accuracy. Any errors will be emailed to the counselor to correct during the next visit with the client.
|
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of seven records reviewed.
Client #7 was admitted on November 7, 2024 and was discharged on March 25, 2025. A release of information form, signed by the client on November 7, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On June 18th, 2025, during the weekly clinical meeting with counselors, the Clinical Supervisor will review completing release of information forms accurately. Attention will be paid to the requirement that a name of person, agency or organization to whom the disclosure is made.
Ongoing, during monthly chart audits, Clinical Supervisor will review the releases that are in the charts for accuracy. Any errors will be emailed to the counselor to correct during the next visit with the client.
|
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
|
Observations
Based on a review of client records, the facility failed to document whether a client participated in the development of the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #4 was admitted on August 27, 2024 and was discharged on December 18, 2024. A comprehensive treatment plan completed on September 25, 2024, did not have written documentation that the client participated in the development of the comprehensive treatment plan.
Client #6 was admitted on June 13, 2024 and was discharged on November 6, 2024. A comprehensive treatment plan completed on June 20, 2024, did not have written documentation that the client participated in the development of the comprehensive treatment plan.
Client #7 was admitted on November 7, 2024 and was discharged on March 25, 2025. A comprehensive treatment plan completed on November 12, 2024, did not have written documentation that the client participated in the development of the comprehensive treatment plan.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
An in-service will be conducted by the Clinical Supervisor on June 25th, 2025, for the counselors to review the policy of completing Comprehensive Treatment Plans that shall be developed with a client, within 30 days of admission. During the review, counselors will be reminded that a signature on the treatment plan indicates the plan was developed with the individual.
If there is an instance where the treatment plan cannot be completed within expected timeframe with the client, a note will be added to the record to indicate attempts made and a plan will be put in place to meet requirements.
It is the responsibility of the Clinical Supervisor to sign off on all treatment plans. Ongoing, if the Clinical Supervisor reviews a plan that does not have client signature, it will be rejected, and counselor will re-submit once signature is obtained, verifying that the client was part of the development process. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment and rehabilitation plan with short and long-term goals for treatment in three of seven client records reviewed.
Client #4 was admitted on August 27, 2024 and was discharged on December 18, 2024. A comprehensive treatment plan was completed on September 25, 2024; however, there were no goals documented on the treatment plan.
Client #6 was admitted on June 13, 2024 and was discharged on November 6, 2024. A comprehensive treatment plan was completed on September 25, 2024; however, there were no goals documented on the treatment plan.
Client #7 was admitted on November 7, 2024 and was discharged on March 25, 2025. A comprehensive treatment plan was completed on September 25, 2024; however, there were no goals documented on the treatment plan.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
An in-service will be conducted by the Clinical Supervisor on June 25th, 2025, for the counselors to review the policy of completing Comprehensive Treatment Plans, that include documenting short and long-term goals.
It is the responsibility of the Clinical Supervisor to sign off on all treatment plans. Ongoing, if the Clinical Supervisor reviews a plan that does not have short and long-term goals, it will be rejected, and the counselor will re-submit once the form has been completed in its entirety.
If a specific counselor continues to not meet the requirements of completing a treatment plan, a corrective action plan will be implemented that will include attending in-depth training related to completion of treatment plans.
|
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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.
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment and rehabilitation plan with the proposed type of support services in three of seven client records reviewed.
Client #4 was admitted on August 27, 2024 and was discharged on December 18, 2024. A comprehensive treatment plan was completed on September 25, 2024; however, the proposed type of support services were not documented.
Client #6 was admitted on June 13, 2024 and was discharged on November 6, 2024. A comprehensive treatment plan was completed on September 25, 2024; however, the proposed type of support services were not documented.
Client #7 was admitted on November 7, 2024 and was discharged on March 25, 2025. A comprehensive treatment plan was completed on September 25, 2024; however, the proposed type of support services were not documented.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
An in-service will be conducted by the Clinical Supervisor on June 25th, 2025, for the counselors to review the standard that a treatment plan shall include proposed type of support service.
It is the responsibility of the Clinical Supervisor to sign off on all treatment plans. Ongoing, if the Clinical Supervisor reviews a plan that does not have details of proposed type of support services it will be rejected, and the counselor will re-submit once the form has been completed in its entirety.
If a specific counselor continues to not meet the requirements of completing a treatment plan, a corrective action plan will be implemented that will include attending in-depth training related to completion of treatment plans.
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client #1 was admitted on January 13, 2025 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on January 24, 2025, indicated that the client was to receive one individual counseling session and one group counseling session per week; however, there were no individual counseling sessions documented for the weeks of February 16, 2025 through February 22, 2025, March 2, 2025 through March 8, 2025, March 16, 2025 through March 22, 2025, March 30, 2025 through April 5, 2025 and April 27, 2025 May 3, 2025.
Client #3 was admitted on February 12, 2025 and was an active client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on February 21, 2025, indicated that the client was to receive one individual counseling session and one group counseling session per week; however, there were no individual counseling sessions documented for the weeks of February 23, 2025 through March 1, 2025, March 9, 2025 through March 15, 2025, March 23, 2025 through March 29, 2025 and April 6, 2025 through April 12, 2025.
Client #4 was admitted on August 27, 2024 and was discharged on December 18, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on September 25, 2024, indicated that the client was to receive one individual counseling session and one group counseling session per week; however, there were no individual counseling sessions documented for the weeks of September 22, 2024 through September 28, 2024, September 29, 2024 through October 5, 2024, October 13, 2024 through October 19, 2024, October 27, 2024 through November 2, 2024 and November 3, 2024 through November 9, 2024.
Client #6 was admitted on June 13, 2024 and was discharged on November 6, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on June 20, 2024, indicated that the client was to receive one individual counseling session and one group counseling session per week; however, there were no individual counseling sessions documented for the weeks of September 1, 2024 through September 7, 2024, September 15, 2024 through September 21, 2024, September 22, 2024 through September 28, 2024, September 29, 2024 through October 5, 2024; and for the month of October 2024.
Client #7 was admitted on November 7, 2024 and was discharged on March 25, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on November 12, 2024, indicated that the client was to receive one individual counseling session and one group counseling session per week; however, there were no individual counseling sessions documented for the weeks of November 24, 2024 through November 30, 2024, December 22, 2024 through December 28, 2024, December 29, 2024 through January 4, 2025, January 26, 2025 through February 1, 2025; and for the months of February 2025 and March 2025.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
An in-service will be conducted by the Clinical Supervisor on June 25th, 2025, for the counselors to review that it is the counselor's responsibility to schedule/provide services according to the treatment plan.
During monthly chart audits completed by the Clinical Supervisor, review of services provided versus services indicated on treatment plan will be reviewed for compliance.
If there are discrepancies, the Clinical Supervisor will provide documented individual supervision to the counselor to discuss discrepancy and ensure compliance.
|
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include discharge summaries entered within seven days of the client ' s discharge, per the facility's policy, in three of four applicable records reviewed.
Client #4 was admitted on August 27, 2024 and was discharged on December 18, 2024. A discharge summary was not documented in the client record at the time of the inspection.
Client #6 was admitted on June 13, 2024 and was discharged on November 6, 2024. A discharge summary was not documented in the client record at the time of the inspection.
Client #7 was admitted on November 7, 2024 and was discharged on March 25, 2025. A discharge summary was not documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On June 18th, 2025, the Clinical Supervisor will meet with the counselors and review the policy of completing a Discharge Summary within 7 days of discharge from the program.
Clinical supervisor will monitor adherence to completion of discharge summaries by auditing 10% of all closed charts every month.
If any discharge summaries are missing, the supervisor will have the primary counselor complete it within 48 hours of notification.
|
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information entered within 30 days of the client ' s discharge, per the facility's policy, in two of four applicable records reviewed.
Client #4 was admitted on August 27, 2024 and was discharged on December 18, 2024. Follow-up information was not documented in the client record at the time of the inspection.
Client #6 was admitted on June 13, 2024 and was discharged on November 6, 2024. Follow-up information was not documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
During clinical meeting on June 18th, 2025, Clinical Supervisor will advise clinical staff to block off time in their schedule each week to focus on completing discharge paperwork, which will include reviewing timelines of when a follow up contact note is due. It will be expected that during their blocked off time for discharge paperwork, completion of Follow Up contact form will occur.
Clinical supervisor will monitor adherence of the follow up contact note being completed by auditing 10% of all closed charts each month.
|