INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-13, 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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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 staff received at least 6 hours of HIV/AIDS and 4 hours of TB/STD within the first two years of employment in one of one applicable records.
Staff #1 was hired at the facility August 5, 2019 and still employed at time of inspection. Communicable disease training was due no later than August 5, 2021. There was no documentation provided for the completion of the trainings as of the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe.
The outstanding trainings for this individual will be completed as soon as they can be scheduled. This is anticipated to be no later than 12/31/26.
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 Gaudenzia Compliance Department will conduct a review of all POC
action items within 90 days to ensure full implementation, identify any
barriers to implementation, and coordinate support, where needed.
Responsible Parties:
- Project Director
- Compliance Department
Staff
Anticipated Completion Date: 12/31/2026 |
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 document an attempted follow up with clients following discharge from the facility in four of four records.
According to agency policy and procedure manual, follow up with discharged clients is as follows: if a referral is made, follow up contact is done within 7 days; all other discharges will follow up within 30 days.
No follow up attempts were documented in the following client records.
Client #1 admitted January 20, 2026 and discharged April 13, 2026.
Client #2 admitted March 25, 2026 and discharged May 30, 2026.
Client #3 admitted March 9, 2026 and discharged June 25, 2026.
Client #4 admitted April 24, 2026 and discharged May 30, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Intake Coordinator will complete the Follow-Up Consent
with clients upon admission. If the Intake Coordinator is not
available, the Counselor, Clinical Supervisor, or other designee
completing the administrative documents at admission will do
so.
Clients' primary counselor will ensure that the Follow-Up Contact Note with current client contact information is
completed prior to or upon discharge from the program. If the counselor is not available, the Clinical Supervisor or other program designee completing the administrative documents at
discharge will do so.
3. After confirming that the Follow-Up Consent is present, the primary counselor of the client will call the client within 7 days after the date of the client's referral appointment.to follow up on her status since discharge. The counselor will document all
attempts to reach the client as well as the result using the Follow-Up Contact Note. If a counselor is not available, the Clinical Supervisor or other program designee will make and document follow-up attempts.
In instances where the client refuses consent for follow-up, such refusal shall be documented on the Follow Up form as well as in a Note to Chart documenting the client's stated
reason for refusal. In instances when the client either refuses a referral to another program or service or circumstances otherwise prevent such a referral (i.e.: the client leaves against staff advice, declines referral to services after discharge, etc.)
an attempt will still be made to follow up with the client within 30 days after the date of discharge and documented on the Follow-Up Contact Form.
During the weekly CQI client chart review process, the Follow-Up Consent and Follow-Up Contact Note will be added
to the review to monitor compliance with post-discharge follow-up contact.
Counselors will utilize the program's discharge checklist and CQI department's documentation timeframes form to ensure
all treatment services and administrative tasks are delivered
and documented in a timely manner. Counselors will submit the checklist to the Clinical Supervisor to assist with
monitoring documentation quality and compliance adherence. Clinical Supervisor will ensure receipt of the checklist within 7 days of a client's discharge.
Clinical Supervisor and/or Program Director will provide supervision and/or progressive discipline when necessary to
ensure compliance with licensing requirements.
The Gaudenzia Compliance Department will conduct a review of all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
Responsible Parties:
- Clinicians
- Clinical Supervisor
- Program Director
- Division Director
- Regional Clinical
Director
- Regional Executive
Director
- Quality Assurance
Manager
- Compliance Department
Staff
Target Completion Date: 9/15/2026 |