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 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.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered as prescribed in two of five records reviewed.
Client #2 admitted December 26, 2025 and discharged February 20, 2026. Suboxone 8mg-2mg sublingual film was prescribed to be given 2 films daily. The MAR was left blank on the following dates: January 12-13, January 18-26, and February 1-5, 2026. Sofosbuvir-velpatasvir 400mg-100mg oral tab was prescribed to be given once daily at bedtime. The MAR was left blank on the following dates: January 22-27, 2026.
Client #4 admitted February 4, 2026 and discharged March 4, 2026. Buprenorphine-naloxone 8mg-2mg sublingual film was prescribed to be given 1 film two times per day. The MAR was left blank on the following dates: February 5-9, February 11-12, February 14-16, February 18, February 22-25, and February 28-March 3, 2026. Bupropion HCL XL 300 mg oral extended release was prescribed to be given 1 tab daily. The MAR was left blank on the following dates: February 5-8, February 15-19, and February 22-March 4, 2026. Buspirone 15mg oral tab was prescribed to be given 1 tab twice daily. The MAR was left blank on the following dates: February 5-9, February 12, February 15-16, February 22-25, and February 28- March 3, 2026. Valacyclovir HCL 500mg oral tab was prescribed to be given once daily. The MAR was left blank on the following dates: Febraury 5-8, February 12-19, and February 22 - March 3, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective November 1, 2026, a Nurse Manager (NM) has been allocated to the program with responsibility for oversight of medication management. The NM will provide oversight of the medication management process, including monitoring medication documentation, identifying missed or incomplete MAR entries, addressing medication-related concerns, and providing education and follow-up with program staff.
The facility staff will be trained no later than 10/9/26 to utilize the EHR Task List as an additional monitoring tool and will utilize the EMAR Missing Administration Report. Staff responsible for medication oversight will review the Task List to identify medications due, incomplete medication-related tasks, and potential missed administrations requiring follow-up. The Nurse Manager and Program Director will routinely review medication documentation, EMAR Missing Administration Report, and Task List completion to identify and address deficiencies.
A standardized competency checklist will be implemented for all non-medical staff responsible for overseeing client self-administration of medications. Following training, each staff member will complete a minimum of two directly observed medication passes with the Nurse Manager or qualified designee and demonstrate proficiency in all required elements of the medication oversight process.
Staff must complete the competency checklist and receive documented approval before independently overseeing client self-administration of medications. Staff who do not demonstrate proficiency will receive additional education and supervised practice and must successfully demonstrate competency before performing medication oversight independently.
The Nurse Manager and Program Director will provide ongoing oversight of medication management and periodically review EMAR documentation, the EMAR Missing Administration Report. and EHR Task List completion for compliance. Identified deficiencies will be addressed through staff education, competency reassessment, and corrective action when indicated. Findings and trends will be used to determine whether additional process improvements or staff education are necessary.
The Nurse Manager or nurse designee will complete a Medication observation (Attached) biannually to monitor compliance with training and policy.
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.
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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 a decision to involuntarily terminate the client's treatment at the project including the reason for termination in one of two applicable client records.
Client #1 admitted January 19, 2026 and administratively discharged on May 31, 2026. A termination letter was documented in client record that failed to identify the reason for termination from the project.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 13, 2025 annual licensure inspection.
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Plan of Correction
All documentation will be completed correctly and in a timely manner to include notifying the client in writing the reason for an involuntary termination utilizing the form created for this purpose in our EHR.
This requirement will be reviewed with all appropriate staff members in a documented in-service training no later than 9/25/26. 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.
The Program Director will review all clients' charts who are involuntarily terminated to ensure the client was notified in writing the reason for involuntary termination.
The Program Director will conduct monthly reviews of clients who are involuntarily terminated from treatment.
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 all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in two of two applicable records.
The facility's policy and procedure manual states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice.
There was a valid release of information for the clients ' emergency contact but no documented attempt to contact the emergency contact following the clients decision to leave against facility advice in the following records.
Client #3 admitted March 26, 2026 and discharged May 9, 2026.
Client #4 admitted February 4, 2026 and discharged March 4, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An ASA Standard Operating Procedure has been implemented. A Review of the ASA Standard Operating Procedure will be facilitated with all staff by the Progam Director no later than 9/25/26.
The Program Director will review all discharge information to include that the Emergency Contact is notified or attempts were made to notify them within 12 hours of an ASA if a release of information signed by the client has been completed. If the required documentation is not found, the clinician or designee will be required to complete this step immediately.
A Note to Chart will be written for all clients who leave ASA to include whether there is an appropriate release of information for an emergency contact and if there is, the contact or attempted contacts made with them.
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 all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to complete case consultations in four of seven applicable records.
Per agency policy and procedures, case consultations are to be completed within 15 days of admission and every 90 days thereafter.
There were no case consultations documented in the following client records.
Client #1 admitted January 19, 2026 and discharged May 31, 2026.
Client #4 admitted February 4, 2026 and discharged March 4, 2026.
Client #5 admitted December 18, 2025 and discharged June 8, 2026.
Client #6 admitted December 10, 2025 and discharged June 24, 2026.
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 to include Case Consultation Notes.
This requirement will be reviewed with all appropriate staff members in a documented in-service training no later than 9/25/26. 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.
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 Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
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
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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 document an attempted follow-up with clients following discharge from the facility in three of six 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 made within 7 days; all other discharges will follow up within 30 days.
No follow-up attempts were documented in the following client records.
Client #3 admitted March 26, 2026 and discharged May 9, 2026.
Client #5 admitted December 18, 2025 and discharged June 8, 2026.
Client #6 admitted December 10, 2025 and discharged June 24, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All follow-up 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 no later than 9/25/26. 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.
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 Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
The Gaudenzia Compliance Department will conduct a review of all POC action steps within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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