INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 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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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, per facility policy, in three of seven records reviewed.
Client # 1 was admitted on July 05, 2024, and was discharged on December 5, 2024. The record contained a progress note for a group session occurring on August 01, 2024, that was not completed until August 19, 2024.
Client #4 was admitted on October 1, 2024, and was active at the time of the inspection. The record contained a progress note for a group session occurring on February 10, 2025, that was not completed until February 20, 2025.
Client #6 was admitted October 9, 2024, and was discharged on March 17, 2025. The record contained a progress note for a group session occurring on February 10, 2025, that was not completed until February 20, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 14th, 2025 during
scheduled clinical meeting, the
clinical supervisor will review the
completion of notes immediately
after the therapy session.
Additionally, the Clinical Supervisor
will be reviewing the counselors'
schedules to ensure that each week
time is scheduled for the completion
of all notes by weeks end.
Ongoing, the Division Director will
run a report reflecting note
completion and will follow up with
Clinical Supervisor on Monday
afternoon that any outstanding
notes will need to be completed by
Tuesday.
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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 seven 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 quarterly, per the facility's policy, in six of seven applicable records reviewed.
Client # 1 was admitted on July 05, 2024 and was discharged on December 05, 2024. The first case consultation note was due to be completed by October 5, 2024; however, it was not completed until October 17, 2024.
Client # 2 was admitted on July 23, 2024 and was discharged on December 4, 2024. The client record did not contain documentation of case consultation notes.
Client # 4 was admitted on October 01, 2024 and was active at the time of the inspection. The first case consultation note was due to be completed by January 1, 2025; however, it was not completed until April 10, 2025.
Client # 5 was admitted on November 21, 2024 and was active at the time of the inspection. The first case consultation note was due to be completed by February 21, 2025; however, it was not completed until March 24, 2025.
Client # 6 was admitted on October 09, 2024 and was discharged on March 17, 2025. The first case consultation note was due to be completed by January 9, 2025; however, it was not completed until March 17, 2025.
Client #7 was admitted on September 18, 2024 and was discharged on February 3, 2025. The first case consultation note was due to be completed by December 18, 2024; however, it was not completed until January 23, 2025.
These findings were reviewed with facility staff during the licensing process
This is a repeat citation from the April 9, 2024 licensing inspection.
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Plan of Correction
Clinical Supervisor will review
current OP workflows during clinical
meeting on May 14th, 2025. The review will include completing case consultations every 90 days as per policy.
Clinical Supervisor and Division Director will continue to complete monthly chart audits that includes monitoring of case
consultations |