INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2025 through May 15, 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. 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and staff schedules, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
The facility is a residential facility with their hours of operation being listed as 24 hours per day, 7 days per week. There were no staff persons with current CPR certification and first aid training working at the facility during the following dates and times: February 7, 2025 from 8:00 PM to 11:00 PM; February 8, 2025 from 3:00 PM to 11:00 PM; February 14, 2025 from 9:00 PM to 11:00 PM; February 22, 2025 from 3:00 PM to 11:00 PM; and February 23, 2025 from 3:00 PM to 11:00 PM.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
GLB had several staff members on duty during the outlined dates specified in the POC to cover the project.
The schedule will at all times provide for at least 1 staff member who is CPR certified on every shift.
All staff members are to complete CPR certification.
Every attempt will be made to ensure that there is more than one CPR certified staff member on each shift in order to anticipate situations such as call-offs.
The Program Director will review the Individual Training Plans 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.
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.
The leadership team and Program Director will review all staffing schedules to ensure that an adequate number of CPR certified staff are on each shift.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate each toilet and washroom by an exhaust fan or a window.
At the time of the inspection, conducted on May 15, 2025 at approximately 12:00 PM, the bathroom exhaust fans in rooms 134 and 137 were not operable and there were no windows in either of the bathrooms.
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 5/13/2025 for maintenance to fully correct the issue. The anticipated completion date is 7/1/2025.
This 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 Deputy Director to address directly with the Maintenance department head.
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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 15, 2025 at approximately 12:00 PM, the toilet stall in bathroom 137 was rusted and the paint was bubbling. Additionally, the shower wall in room 134 had paint and drywall that was peeling.
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 4/11/25 for maintenance to fully correct the issue. The anticipated completion date is 7/1/2025.
This 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 Deputy Director to address directly with the Maintenance department head
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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 extinguisher upon staff employment in one of three applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on February 10, 2025. The personnel record documented that the fire extinguisher training was not completed until April 26, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As a part of week 1 staff orientation, all new hires will receive fire extinguisher training within the first seven days of employment by the Administrative Coordinator and submitted for approval by the Program Director.
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.
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.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on an administrative review of the July 2024 through March 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the review, there was no fire drill completed and documented during the month of September 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program will conduct unannounced fire drills at least once a month on each shift.
This requirement will be reviewed with all appropriate staff members; a documented in-service training within the next two weeks, and no later than 7/1/2025. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the form with which to document this information, and; how to request assistance when needed.
The Program Director will review fire drill logs prior to the end of each month to ensure that fire drills are conducted as required.
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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 are trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on February 10, 2025. The documentation in the personnel record indicated the training to perform assigned tasks during emergencies was not completed until April 26, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As a part of week 1 staff orientation, all new hires will receive emergency training within the first seven days of employment by the Administrative Coordinator and submitted for approval by the Program Director.
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.
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.
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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 two of two applicable client records reviewed.
Client # 1 was admitted to the inpatient non-hospital detoxification activity on August 10, 2024, and was administratively discharged on August 13, 2024. 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.
Client # 11 was admitted to the inpatient non-hospital activity on September 5, 2024, and was administratively discharged on September 16, 2024. 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
All documentation will be completed correctly and in a timely manner.
Clinical Supervisor and Program Director will review the policy with staff by 7/1/2025 to ensure completion of 709.33 (a). This will ensure ongoing compliance regarding the Notification of Termination.
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.
Additionally, we immediately added a hard copy of document to client's belongings packet they sign confirming receipt of safe items (phone, wallet, etc.). Once signed, documents are entered and specifically labeled Treatment Termination Notice.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) 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 three of seven applicable client records reviewed.
Client # 1 was admitted to the inpatient non-hospital detoxification activity on August 10, 2024 and was discharged on August 13, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 2 was admitted to the inpatient non-hospital detoxification activity on November 21, 2024 and was discharged on November 24, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 7 was admitted to the inpatient non-hospital detoxification activity on March 8, 2025 and was discharged on March 14, 2025. There was no follow-up information 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 documentation will be completed 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 5/19/2025. 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 5/19/2025.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in three of seven applicable client records reviewed.
Client # 8 was admitted to the inpatient non-hospital activity on March 28, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 31, 2025; however, the plan did not include the proposed type of support services.
Client # 9 was admitted to the inpatient non-hospital activity on April 28, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 5, 2025; however, the plan did not include the proposed type of support services.
Client # 10 was admitted to the inpatient non-hospital activity on April 16, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 20, 2025; however, the plan did not include the proposed type of support services.
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.
This requirement has been reviewed with all appropriate staff members in a documented in-service training on 5/19/25. This training included 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 7/1/2025.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
**Meeting held with counselors on 5/19/25 to review and implement change immediately.
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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 a discharge summary, in three of four applicable client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on September 5, 2024 and was discharged on September 16, 2024. There was no discharge summary documented in the client record at the time of the inspection.
Client # 12 was admitted to the inpatient non-hospital activity on February 12, 2025 and was discharged on March 28, 2025. There was no discharge summary documented in the client record at the time of the inspection.
Client # 14 was admitted to the inpatient non-hospital activity on November 8, 2024 and was discharged on December 31, 2024. There was no discharge summary 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
All documentation will be completed correctly and in a timely manner.
This requirement has been reviewed with all appropriate staff members in a documented in-service training on 5/19/25. This training included 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 5/19/2025.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
**Meeting held with counselors on 5/19/25 to review and implement change immediately.
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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 four of four applicable client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on September 5, 2024 and was discharged on September 16, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 12 was admitted to the inpatient non-hospital activity on February 12, 2025 and was discharged on March 28, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 13 was admitted to the inpatient non-hospital activity on November 11, 2024 and was discharged on December 19, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 14 was admitted to the inpatient non-hospital activity on November 8, 2024 and was discharged on December 31, 2024. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the May 12, 2022, April 21, 2023, and May 17, 2024 annual licensing inspections.
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.
This requirement has been reviewed with all appropriate staff members in a documented in-service training on 5/19/25. This training included 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 7/1/2025.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
**Detail of Discharges will be reviewed daily to identify calls needed for day/week/month.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in six of seven applicable client records reviewed.
Client # 15 was admitted to the outpatient activity on January 24, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 31, 2025; however, the plan did not include the proposed type of support services.
Client # 16 was admitted to the outpatient activity on October 28, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 11, 2024; however, the plan did not include the proposed type of support services.
Client # 17 was admitted to the outpatient activity on February 13, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 19, 2025; however, the plan did not include the proposed type of support services.
Client # 18 was admitted to the outpatient activity on September 20, 2024 and was discharged on January 13, 2025. The individual treatment and rehabilitation plan was completed on October 9, 2024; however, the plan did not include the proposed type of support services.
Client # 19 was admitted to the outpatient activity on November 18, 2024 and was discharged on March 5, 2025. The individual treatment and rehabilitation plan was completed on December 4, 2024; however, the plan did not include the proposed type of support services.
Client # 21 was admitted to the outpatient activity on September 26, 2024 and was discharged on March 31, 2025. The individual treatment and rehabilitation plan was completed on October 14, 2024; however, the plan did not include the proposed type of support services.
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.
This requirement has been reviewed with all appropriate staff members in a documented in-service training on 5/19/25. This training included 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 5/19/2025.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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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 not documenting follow-up information in the client record was submitted and approved by the Department for the May 12, 2022, April 21, 2023, and May 17, 2024, annual licensing inspections. Not documenting follow-up information in the client record was again found to be a deficiency in the May 14, 2025 through May 15, 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.
Implementation 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 Deputy Director will meet with the Program Director at least monthly in documented supervision sessions to review and identify barriers to the implementation of each action item.
Any barriers noted will be addressed as appropriate.
The Program Director will report at least monthly to the Deputy Director regarding any outstanding items, identified barriers, or other areas requiring improvement.
Any areas noted as not meeting the requirements listed above 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 to full compliance.
Information from previous inspections will be reviewed to assist program leadership in its implementation of a new plan of correction.
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