INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 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. Broad Street 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure each employee had a written, annual individual training plan, with input from the employee and the supervisor, documented in one of five personnel records reviewed.
Employee #3 was hired as a clinical supervisor on May 13, 2022. The individual training plan was signed by the employee's supervisor on January 3, 2025; however, the plan did not include a signature from the employee or other documentation indicating the plan was completed with employee input.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with employee and fully complete his individual training plan by close of business on 6/4/2025. To avoid reoccurrence of issue, program director will meet with Clinical supervisor at least 1 x monthly to review training plans for all employees and to ensure all training plans are completed and properly signed |
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 records reviewed.
Employee # 2 was hired as the facility director on November 21, 2022. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training was due to be completed no later than November 21, 2024; however, the HIV/AIDS training was completed on April 1, 2025 and the tuberculosis, sexually transmitted diseases, and other health related topics training was completed on March 21, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff has now successfully completed HIV/TB/STI trainings and has been verified by program director. To avoid reoccurrence, program director will meet 2x a month with new administrative coordinator to review and schedule all employees with required trainings. this starts 6/6/2025. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure cold food was kept at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
At the time of the inspection, conducted at approximately 12:50 pm, the freezer, which is located behind the walk-in refrigerator in the kitchen, registered a temperature of 18 degrees fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director meet with building operations director to make sure freezer was operating correctly. Work order was submitted to vendor to replace seals on outer freezer door that was letting out cold air. Vendor assured seals will be replaced by 6/11/2025. to prevent reoccurrence, program director will increase physical plant audits assigned to RSP's to include kitchen areas including freezers at least 1x weekly. this will begin 6/11/2025. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed.
At the time of the inspection, conducted at approximately 12:50 pm, there was a portable space heater located in the counselor's office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director made individual inspections of all offices in addition to sending out emails to all employees to remind them of policy against having personal heaters that are not mounted to walls in any offices. Program Director removed heater from cited office on 6/4/2025. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment in two of two applicable personnel records reviewed.
Employee # 5 was hired as a counselor on March 10, 2025. There was documentation in the personnel record indicating the fire extinguisher training was completed; however, there was no date on the training certificate to verify if the training was completed upon staff employment.
Employee # 6 was hired as a recovery support specialist on December 9, 2024. There was documentation in the personnel record indicating the fire extinguisher training was completed; however, there was no date on the training certificate to verify if the training was completed upon staff employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has reviewed all safety certificates and ensured all are now properly dated to reflect their training. to avoid reoccurrence, program director will review all employee Fire Safety trainings with new administrative coordinator on monthly basis starting 6/9/25. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel, on all shifts, were trained to perform assigned tasks during emergencies in two of two applicable personnel records reviewed.
Employee # 5 was hired as a counselor on March 10, 2025. There was documentation in the personnel record indicating the emergency preparedness training was completed; however, there was no date on the training certificate to verify when the training as completed.
Employee # 6 was hired as a recovery support specialist on December 9, 2024. There was documentation in the personnel record indicating the emergency preparedness training was completed; however, there was no date on the training certificate to verify when the training as completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has reviewed all safety certificates and ensured all are now properly dated to reflect their training. to avoid reoccurrence, program director will review all employee Fire Safety trainings with new administrative coordinator on monthly basis starting 6/9/25. |
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 their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
The facility policy related to AMA discharges of a client is the emergency contact will be called within twelve hours of the client leaving treatment.
Client # 6 was admitted on September 18, 2024 and was discharged against medical advice on September 26, 2024. There was no documentation in the record indicating the emergency contact was notified of the client's treatment status.
This is a repeat citation from the May 15, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program director will meet with clinical supervisor weekly to ensure chart audits are done 3x a week to ensure all emergency contacts were notified for anyone leaving ASA this will start immediately. |
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 the documentation of discharge summary, in two of four applicable records reviewed.
Client # 5 was admitted on October 16, 2024 and was discharged on November 1, 2024. There was no discharge summary documented in the record as of the date of the inspection.
Client # 7 was admitted on January 2, 2025 and was discharged on January 13, 2025. There was no discharge summary documented in the record as of the date of the inspection.
This is a repeat citation from the May 15, 2024 annual licensing renewal inspection.
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Plan of Correction
Program director will meet with clinical supervisor weekly to ensure chart audits are done 3x a week to ensure all Discharge Summaries and other clinical documentation pertaining to client charts are submitted in timely manner. This will start immediately. |
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 the documentation of follow-up information, in two of four applicable records reviewed.
Client # 4 was admitted on October 16, 2024 and was discharged on November 1, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted on January 2, 2025 and was discharged on January 13, 2025. There was no follow-up information 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
Program director will meet with Care Coordinator weekly to review all discharges from previous week has a follow up contact note completed and entered into chart. This will start immediately. |
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 personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring all staff received the HIV/AIDS training and the TB/STD training within the regulatory timeframe was submitted and approved by the Department for the June 22, 2023, and May 15, 2024 annual licensing inspections. Failing to ensure all staff received the communicable disease trainings was again found to be a deficiency in the May 21, 2025 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will implement new system where Program Director, Clinical Supervisor, as well as Administrative Coordinator all will monitor and track status of employee trainings and review results in separate quarterly staff meeting to ensure all employees have all required trainings in timely manner. To avoid reoccurrence and not following past POCs, Program director will add specific POC audit review to every monthly clinical staff meeting. |