INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 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 - New Destiny 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 on May 5, 2025, the facility failed to keep the ground of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
Locked heater plates were bent in rooms 105 and 108, allowing access to the interior wiring and sharp metal parts of the heater.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A work order was immediately completed to have these plates replaced. The plates have been removed, the opening has been covered with no access to interior wiring, and sharp metal plates have been filed down to avoid injury while awaiting new plates. The replacement of the new plate should be completed by the end of June 2025. The house runs sheet was updated to include a plate covering to be checked in each room when house runs are complete, and added to the room condition sheet, which is checked before a new client moves into that room.
Staff, the Program Director, and Maintenance will monitor ongoing compliance through monthly review of the run sheets. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection on May 5, 2025, the facility failed to ensure that there are slip-resistant surfaces in all bathtubs and showers.
The showers or bathtubs in the bathrooms connected to rooms 105, 107a and 107b were missing slip-resistant mats/strips.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Slip-resistant strips were purchased and installed in bathrooms connected to rooms 105, 107A, and 107 B. The program will check monthly when the safety report is completed and will have slip-resistant mats in stock at the facility, needing replacement, or missing. Checking for Slip-resistant strips/Mats will be checked monthly, and during daily house runs.
Ongoing compliance will be monitored by RSP, RSP supervisor, and Program Director
Completed 05/08/2025 |
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 the review of four personnel records and staff training records, the project failed to instruct three staff in the use of the fire extinguisher upon employment.
Employee #3 was hired as the facility director on June 24, 2024, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training until July 8, 2024.
Employee #4 was hired as a counselor on July 1, 2024, and was in the position of clinical supervisor at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training until July 15, 2024.
Employee #5 was hired as a counselor on November 4, 2024, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training until December 6, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This has been corrected and updated on the individual training plan generated for all new hires on their first day. The plan is checked at the end of each day to ensure training is completed by the due date and recorded in our web-based Relias training system. Moving forward, staff complete this training on the very first day of employment at the facility.
The Administrative Assistant and Program Director will monitor ongoing compliance to ensure training is completed through daily review of training documentation for new hires and quarterly review of training documentation for all other employees.
Completed 05/22/2025 |
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 the review of four personnel records and staff training records, the project failed to ensure that three personnel were trained to perform assigned tasks during emergencies.
Employee #3 was hired as the facility director on June 24, 2024, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this training until July 8, 2024.
Employee #4 was hired as a counselor on July 1, 2024, and was in the position of clinical supervisor at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this training until July 15, 2024.
Employee #5 was hired as a counselor on November 4, 2024, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this training until December 6, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
This has been corrected and updated on the individual training plan that is generated for all new hires, on their first day, and checked at the end of each day to ensure trainings are completed by
The due date is recorded in our web-based Relias training system. From now on, staff will complete this training on their first day of employment at the facility.
The Administrative Assistant and Program Director will monitor ongoing compliance to ensure training is completed through daily review of training documentation for new hires and quarterly review of training documentation for all other employees.
Completed 05/22/2025 |
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 the review of client records, the project failed to document a complete client record on an individual that included follow-up contact in two of four applicable records reviewed.
Client # 4 was admitted on September 19, 2024 and was discharged on December 3, 2024. There was no follow-up contact information documented in the client record seven days post discharge: per the facility ' s policies and procedures.
Client # 5 was admitted on November 26, 2024 and was discharged on February 20, 2025. There was no follow-up contact information documented in the client record seven days post discharge: per the facility ' s policies and procedures.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The program director met with the counselors and reinforced that follow-up contact must be completed within the required timeframe. The program director created a checklist from admission to discharge that each counselor will complete and a clinical supervisor will sign off on for each client admitted into the program. A clinical supervisor will monitor the checklist. Once a client is discharged and follow-up is completed, the clinical supervisor and program director will sign off on it as completed.
The clinical supervisor and program director will monitor ongoing compliance during monthly reviews of a sample of charts.
Completed 05/23/2025 |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by clients at the project is an integral part of their treatment and rehabilitation plan in all seven records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Tx plans were reviewed with clients, and a goal was added to each client's treatment plan. The program director met with counselors to reinforce the need for activities of daily living skills to be reviewed with each client and added to their treatment plan upon entry to the program.
The clinical supervisor will be the ongoing monitor of compliance, ensuring completion when approving treatment plans. The Program director will assist if the clinical supervisor is out and will monitor treatment plans monthly for compliance during the review of a sample of charts.
Completion: 05/21/2025 |