INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21, 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 At Sunbury 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on review of client records, the facility failed to obtain completed informed and voluntary consent which included the specific information to be disclosed in one out seven records reviewed.
Client #7 was admitted on July 08, 2025, and was discharged on September 03, 2025. A release of information form for an emergency contact was signed and dated July 08, 2025; however, it did not include the specific information to be disclosed for family sessions. Husband attended family session per progress note.
This finding was reviewed with facility staff during the licensing process.
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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 to include the specific information to be disclosed.
This requirement will be reviewed by the Clinical Supervisor with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. 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.
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 and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in two out of seven client records reviewed.
Client #2 was admitted on October 14, 2025, and discharged on December 03, 2025. A consent form signed and dated February 14, 2025, for the emergency contact, did not have documentation that the client was offered a copy of the consent form.
Client #6 was admitted on February 17, 2026, and discharged on March 05, 2026. A consent form signed and dated February 17, 2026, for a funder, cps, and cys did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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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 to include indicating the client was offered a copy of the consent.
This requirement will be reviewed by the Program Director with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/29/26. 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.
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 and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.93(a)(8) 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:
(8) Case consultation notes.
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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 case consultation notes entered within 90 days of the date of service, per the facility's policy, in two of four applicable records reviewed.
Client #1 was admitted on October 07, 2023, and was a current client at the time of the licensing inspection. A case consultation was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #3 was admitted on October 28, 2025, and was a current client at the time of the licensing inspection. A case consultation was not documented in the record until March 06, 2026, which is not within the 90 days of admission per the facility's policy.
This is a repeat citation from May 14, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner to include completing Case Consultation notes according to Gaudenzia's Policy.
This requirement will be reviewed with all appropriate staff members by the Clinical Supervisor in a documented in-service training within the next two weeks, and no later than 5/29/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 5/22/26.
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.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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.
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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 three of three applicable records reviewed.
Client #2 was admitted on October 14, 2025 and discharged on December 03, 2025. Follow-up information was not documented in the client record at the time of the inspection.
Client #6 was admitted on February 17, 2026, and was discharged on March 05, 2026. Follow-up information was not documented in the client record at the time of the inspection.
Client #7 was admitted on July 08, 2025, and was discharged on September 03, 2025. Follow-up information was not documented in the client record at the time of the inspection.
This is a repeat citation from May 14, 2025 annual licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner to include completing a follow-up contact per Gaudenzia's policy.
This requirement will be reviewed with all appropriate staff members by the Clinical Supervisor in a documented in-service training within the next two weeks, and no later than 5/29/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 5/22/26.
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.
The Gaudenzia Compliance Department will conduct a review of the POC within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed
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