INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 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 Washington House 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 all staff persons received at least 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 within the regulatory time frame in one of one applicable personnel record reviewed.
Employee # 4 was hired as a counselor on July 3, 2023. The HIV/AIDS and TB/STD trainings were due no later than July 3, 2024. There was documentation of a 1-hour HIV/AIDS training completed on July 12, 2023; however, the training was not a Department-approved curriculum and also did not meet the required hours. Additionally, the TB/STD training was not completed as of the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe. Outstanding training will be completed absolutely as soon as they can be scheduled. This is anticipated to be no later than 6/30/25.
Employee # 4 is scheduled for TB/STD Training on 6/13/2025 and HIV/AIDS on 6/30/25
All staff members have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements. The Supervisor will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion. Certificates of completion as well as Evaluations will be maintained in the staff file. The Clinical Supervisor and Program Director will review the Individual Training Plans weekly for new hires, and at least quarterly for all staff. Staff who have upcoming training due dates within the next quarter will be reminded of this and the Supervisor will work with them to schedule training sessions prior to the due dates and will monitor to ensure full and timely completion. Completion Date:
If any issues are noted with staff failing to complete scheduled trainings, this will be specifically addressed with them in a documented supervision session with a clear plan to have all trainings completed. If any issues are noted with unavailability of required training session opportunities, this will be addressed with the Division Director and the Deputy Director to assist in advocating with the training provider. |
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 functional, clean and sanitary manner at all times.
At the time of the inspection, conducted on May 7, 2025 at approximately 9:50 AM, there were multiple shower stalls, located in the facility ' s client-shared bathroom, that had chipped and peeling paint.
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.
A work order was filed on June 10, 2025, for maintenance to fully correct the issue. The anticipated completion date is 6/30/25.
The 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 Division Director and Deputy Director to address directly with the Maintenance department head. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on an administrative review of the May 2024 through March 2025 fire drill logs, the facility failed to set off a fire alarm or smoke detector for every fire drill conducted and documented during the reviewed period.
This is a repeat citation from the April 29, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program staff conducting the drill will communicate and coordinate with the other program co-located in the same facility to ensure that the alarm is sounded for every drill.
The Program Director will oversee this process and review all documentation afterwards to ensure that all requirements are met, and all documentation is completed. |
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 one applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client # 6 was admitted on December 23, 2024 and was discharged against medical advice on March 19, 2025; however, there was no documentation that the emergency contact was notified of the client's discharge.
This is a repeat citation from the May 26, 2022 and June 12, 2023, and April 29, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When a member leaves the program ASA, the primary counselor will notify the Emergency Contact within 12 hours. If the primary counselor is not present, the RSP will be responsible for notifying the Emergency Contact. In all cases, an Emergency Contact follow-up note will be completed in the client's chart.
The Program Director will review the policy with all staff in an in-service training no later than 6/30/25. The Administrative Assistant will run the Detail of Discharges by Program report 2x weekly to ensure all clients who left ASA had emergency contact follow-up note completed. If it was not completed the Program Director and/or assigned counselor will complete the follow-up call and document, it in the client's chart. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their client rights in five of seven client records reviewed.
The facility policy and procedure manual states "the client will be required to sign a formal document that states they have read and fully understood the information contained in the orientation manual." The orientation manual includes the client rights.
Client # 3 was admitted on February 28, 2025 and was still active at the time of the inspection. There was no documentation, in the record, of a client rights acknowledgement or a signed document indicating they had received, read, and understood the information in the orientation manual.
Client # 4 was admitted on August 27, 2024 and was discharged on November 9, 2024. There was no documentation, in the record, of a client rights acknowledgement or a signed document indicating they had received, read, and understood the information in the orientation manual.
Client # 5 was admitted on January 24, 2025 and was discharged on March 21, 2025. There was no documentation, in the record, of a client rights acknowledgement or a signed document indicating they had received, read, and understood the information in the orientation manual.
Client # 6 was admitted on December 23, 2024 and was discharged on January 25, 2025. There was no documentation, in the record, of a client rights acknowledgement or a signed document indicating they had received, read, and understood the information in the orientation manual.
Client # 7 was admitted on December 9, 2024 and was discharged on March 19, 2025. There was no documentation, in the record, of a client rights acknowledgement or a signed document indicating they had received, read, and understood the information in the orientation manual.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will have their rights explained to them at admission and will acknowledge their receipt and understanding of their rights via signature.
This requirement will be reviewed with all staff in an in-service no later than 6/30/25. This will include review of the Workflow, this specific requirement, and the forms utilized to document this.
The Program Director will complete at least monthly reviews of sample charts in order to monitor compliance. Any issues noted will be addressed in a documented supervision session and corrected within 48 hours |
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 # 6 was admitted on December 25, 2025 and was administratively discharged on January 25, 2025. There was no documentation in the record indicating that 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
Any time a client is to be involuntarily terminated from the program, they will be given written notification of such. This is completed via a specific form in our EHR.
This requirement will be reviewed with all staff in an in-service no later than 6/30/25. This will include review of the Workflow, this specific requirement, and the form utilized to document this.
The Program Director will complete at least monthly reviews of a sample of charts in order to monitor compliance. Any issues noted will be addressed in a documented supervision session and corrected within 48 hours.
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709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, during the intake and admission process, in five of seven client records reviewed.
The facility policy and procedure manual states that "the client will be required to sign a formal document that states they have read and fully understood the information contained in the orientation manual."
Client # 3 was admitted on February 28, 2025 and was still active at the time of the inspection. There was no documentation, in the record, of a signed document indicating the client read and fully understood the information contained in the orientation manual.
Client # 4 was admitted on August 27, 2024 and was discharged on November 9, 2024. There was no documentation, in the record, of a signed document indicating the client read and fully understood the information contained in the orientation manual.
Client # 5 was admitted on January 24, 2025 and was discharged on March 21, 2025. There was no documentation, in the record, of a signed document indicating the client read and fully understood the information contained in the orientation manual.
Client # 6 was admitted on December 23, 2024 and was discharged on January 25, 2025. There was no documentation, in the record, of a signed document indicating the client read and fully understood the information contained in the orientation manual.
Client # 7 was admitted on December 9, 2024 and was discharged on March 19, 2025. There was no documentation, in the record, of a signed document indicating the client read and fully understood the information contained in the orientation manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will have the orientation manual reviewed with them at admission and will acknowledge their receipt and understanding via signature.
This requirement will be reviewed with all staff in an in-service no later than 6/30/25. This will include review of the Workflow, this specific requirement, and the forms utilized to document this.
The Program Director will complete at least monthly reviews of a sample of charts in order to monitor compliance. Any issues noted will be addressed in a documented supervision session and corrected within 48 hours. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment, during the intake and admission process, in six of seven client records reviewed.
The facility policy and procedure manual states "The client will sign an informed Consent to Treatment Form" as part of the client orientation process.
Client # 2 was admitted on February 20, 2025 and was still active at the time of the inspection. There was no consent to treatment documented in the record at the time of the inspection.
Client # 3 was admitted on February 28, 2025 and was still active at the time of the inspection. There was no consent to treatment documented in the record at the time of the inspection.
Client # 4 was admitted on August 27, 2024 and was discharged on November 9, 2024. There was no consent to treatment documented in the record at the time of the inspection.
Client # 5 was admitted on January 24, 2025 and was discharged on March 21, 2025. There was no consent to treatment documented in the record at the time of the inspection.
Client # 6 was admitted on December 23, 2024 and was discharged on January 25, 2025. There was no consent to treatment documented in the record at the time of the inspection.
Client # 7 was admitted on December 9, 2024 and was discharged on March 19, 2025. There was no consent to treatment documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will review a Consent to Treatment at admission and will acknowledge their receipt and understanding of this consent via signature.
This requirement will be reviewed with all staff in an in-service no later than 6/30/25. This will include review of the Workflow, this specific requirement, and the forms utilized to document this.
The Program Director will complete at least monthly reviews of a sample of charts in order to monitor compliance. Any issues noted will be addressed in a documented supervision session and corrected within 48 hours. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in three of seven client records reviewed.
The policy and procedure manual states the individual treatment and rehabilitation plan is to be completed within 7 days of admission.
Client # 3 was admitted on February 28, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than March 7, 2025; however, it was completed on March 13, 2025. Additionally, there was no documentation in the record indicating the treatment plan was developed with the client.
Client # 4 was admitted on August 27, 2024 and was discharged on November 9, 2024. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client # 6 was admitted on December 23, 2024 and was discharged on January 25, 2025. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Initial Treatment plans will be completed within 7 days of admission for all clients.
This requirement will be reviewed with all clinical staff in an in-service no later than 6/30/25. This will include review of the Workflow, this specific requirement, and all forms utilized to document this.
The Program Director will complete at least monthly reviews of a sample of charts in order to monitor compliance. Any issues noted will be addressed in a documented supervision session and corrected within 48 hours. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in three of five applicable client records reviewed.
Client # 2 was admitted on February 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 25, 2025 and an update was due no later than March 25, 2025; however, the update was not completed until April 9, 2025.
Client # 5 was admitted on January 24, 2025 and was discharged on March 21, 2025. The individual treatment and rehabilitation plan was completed on January 30, 2025 and an update was due no later than March 1, 2025; however, the update was not completed until March 7, 2025.
Client # 7 was admitted on December 9, 2024 and was discharged on March 19, 2025. The individual treatment and rehabilitation plan was completed on February 4, 2024 and an update was due no later than March 6, 2025; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plan updates will be completed within 30 days from the date of the Comprehensive Treatment plan.
The Administrative Assistant will send a reminder to counselors at the beginning of each month noting which clients are due for Treatment Plan updates.
Counselors will send all Treatment Plans to Program Director for approval. Program Director will conduct monthly reviews of random charts using our internal review tool to ensure that Treatment Plans are completed in a timely manner.
Program Director will alert counselors of any missing documentation, and it must be completed and submitted to Program Director for review within 48 hours.
This requirement will be reviewed with staff in an in-service no later than 6/30/25. This will include review of the Workflow, this specific requirement, and the forms utilized to document this.
The Program Director will complete at least monthly reviews of a sample of charts in order to monitor compliance. Any issues will be addressed in a documented supervision session and corrected within 48 hours. |
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 a review of client records, the facility failed to maintain a complete client record, which is to include documentation of a discharge summary, in three of four applicable client records reviewed.
Client # 5 was admitted on January 24, 2025 and was discharged on March 21, 2025. There was no discharge summary documented in the record at the time of the inspection.
Client # 6 was admitted on December 23, 2024 and was discharged on January 25, 2025. There was no discharge summary documented in the record at the time of the inspection.
Client # 7 was admitted on December 9, 2024 and was discharged on March 19, 2025. There was no discharge summary documented in the record at the time of the inspection.
This is a repeat citation from the June 12, 2023 and April 29, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Counselor is responsible for completing the discharge client information.
The Program Director will monitor all discharges to ensure that discharge summary has been completed and submitted within (7 days) in accordance with 3.1 Workflow schedule.
The Program Director will review missing documentation with the counselor who will have documentation completed within 48 hours. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) 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 documentation of follow-up information, in four of four applicable client records reviewed.
Client # 4 was admitted on August 27, 2024 and was discharged on November 9, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 5 was admitted on January 24, 2025 and was discharged on March 21, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 6 was admitted on December 23, 2024 and was discharged on January 25, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 7 was admitted on December 9, 2024 and was discharged on March 19, 2025. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the May 26, 2022 and June 12, 2023, and April 29, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assigned Counselor will complete follow-up notes within (7 days) of aftercare appointment or within (7 days) of discharge.
Administrative Assistant will run a weekly Detail of Discharge by Program Report from EHR identifying which client requires a follow-up contact note.
The Program Director will review this report with counselors at weekly Treatment Team meeting to identify which clients are due for follow-ups. This process will be reviewed with the Administrative Assistant and Counselors in an in-service training no later than 6/30/25. |
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 failing to notify an emergency contact within 12 hours after a client is discharged from the facility against medical advice was submitted and approved by the Department for the May 26, 2022, June 12, 2023, and April 29, 2024 annual licensing inspections. Failing to notify an emergency contact within 12 hours after a client is discharged from the facility against medical advice was again found to be a deficiency in the May 7, 2025 annual licensing inspection.
A plan of correction for failing to document a discharge summary in the client record was submitted and approved by the Department for the June 12, 2023 and April 29, 2024 annual licensing inspections. Failing to document a discharge summary in the client record was again found to be a deficiency in the May 7, 2025, licensing inspection
A plan of correction for failing to document follow-up information in the client record was submitted and approved by the Department for the May 26, 2022, June 12, 2023, and April 29, 2024, annual licensing inspections. Failing to document follow-up information in the client record was again found to be a deficiency in the May 7, 2025 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.
This 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 updates on implementation of each action item.
The Division Director will report at least monthly to the Deputy Director regarding any outstanding items or other areas for improvement.
Any areas noted as not meeting the action items listed 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.
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