INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19, 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. Fountain Springs 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
At the time of the inspection, conducted at approximately 1:00 pm, the grates covering the wall heaters in bedrooms 104 and 108 were covered in rust, which was starting to break off of the grates.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A work order was submitted on 5/19/26 for the grates to either be replaced or fixed as needed. The work is expected to begin no later than 6/15/26. The Program Director will be responsible for ensuring the grates are replaced or fixed. Until the grates can be replaced or fixed, the grates that have rust have been spray painted with the appropriate paint to prevent any rust from breaking off. This was completed on 6/4/26/26.
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 Division Director and Regional Executive Director to address directly with the Maintenance department head.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
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 clean and sanitary manner at all times.
At the time of the inspection, conducted at approximately 1:00 pm, the first-floor client-shared bathroom had a shower stall with patches of what appeared to be a black mold-like substance. Additionally, the second-floor client-shared bathroom had a tub with what appeared to be a black mold-like substance.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The physical plant will be properly maintained at all times.
The areas identified have been thoroughly cleaned and although it was determined not to be mold, a work order was submitted on 5/19/26 to replace the caulking which will occur by 6/30/26.
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 Division Director and Regional Executive Director to address directly with the Maintenance department head.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure cold food was kept at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
At the time of the inspection, conducted at approximately 1:10 pm, the freezer registered an internal temperature of 30 degrees Fahrenheit.
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
The freezer temperature has been checked every day since the inspection and has been found to be maintaining the temperature below 0F. to ensure the freezer is properly sealed, new seals for the freezer have been ordered and will be installed by 6/30/26. It is believed the temperature was not below 0F at inspection time due to the number of times the door had been opened for lunch preparation.
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 Division Director and Regional Executive Director to address directly with the Maintenance department head.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
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 and the project policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of four applicable records reviewed.
The policy and procedure manual stated that follow-up information will be completed within 7 days of discharge.
Client # 6 was admitted on September 15, 2025 and was discharged on October 7, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 7 was admitted on September 5, 2025 and was discharged on September 15, 2025. The documentation of follow-up information was due to be completed by September 22, 2025, but follow-up information was not documented in the record until September 26, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
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 6/15/26. 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 follow-up information for any 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 6/12/26.
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.
All follow-up documentation will be completed in a timely manner.
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 all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |