INITIAL COMMENTS
|
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 Together 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:
|
Plan of Correction
|
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.
|
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 client records reviewed.
The facility policy and procedure for against medical advice/against staff advice discharges (AMA/ASA) stated that if the individual is discharged, then their emergency contact will be notified within 12 hours in order to help ensure a support system is available once they leave the program.
Client # 7 was admitted on October 6, 2025 and was discharged against staff advice on November 17, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's discharge at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The individual's emergency contact will be notified within 12 hours of any client leaving against staff advice.
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/AMA by 7/3/26. The review will include how to document contact or attempts to contact the client's emergency contact.
The Clinical Supervisor will review all ASA/AMA discharges to ensure the emergency contact, if a proper release is in place, has been notified and attempts made are documented in the client's chart. If no attempt has been made and documented, the Clinical Supervisor will ensure the contact is made immediately either by themselves or the clinician.
The Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess the presence, timeliness and quality of each chart document.
The Gaudenzia Compliance Department will conduct a review of the plan of correction within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
|
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 a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of eight client records reviewed.
Client # 1 was admitted on September 8, 2025 and was discharged on November 11, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An informed and voluntary consent from the client for the disclosure of information contained in the client record will be completed fully, 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 7/3/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing releases for any active client will be updated within 1 week and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 7/3/26.
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 Division Director in regular supervision sessions, and any barriers to implementation will be 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.
|