INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 01, 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. Fulton County Outpatient 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of seven client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed.
Client #5 was admitted on September 17, 2025, and was still active at the time of the inspection. There was documentation that information was disclosed to an outside pharmacy on December 12, 2025; however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.
This is a repeat citation from March 11, 2025, annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An informed and voluntary consent from the client for the disclosure of information contained in the client record will be completed fully, 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 5/8/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing releases for any active client will be updated within 1 week and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 5/8/26.
The Program Director will complete at least weekly 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 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 any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information every 90 days of in five of seven applicable records reviewed.
Client #2 was admitted on August 12, 2025 and still was active at the time of the inspection. There was no documentation of case consultation information in the record at the time of the inspection.
Client #3 was admitted on October 07, 2025 and was active at the time of the inspection. A case consultation was due no later than January 07, 2026, however; one was not documented until January 27, 2026.
Client #4 was admitted on June 23, 2025 and discharged on February 07, 2026. A case consultation was due no later than September 23, 2025, however; one was not documented until February 08, 2026.
Client #5 was admitted on September 17, 2025 and still was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #6 was admitted on May 28, 2025 and still was active at the inspection. There was no documentation of case consultation information in the record.
This is a repeat citation from both April 24, 2024 and March 11, 2025 annual licensing 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, to include Case Consultation notes.
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 5/8/26. 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 or incorrect documentation for any active client will be updated within 1 week and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 5/8/26.
The Program Director will complete at least weekly 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 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 any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary, in two out of three applicable records reviewed. Per the facility's policy and procedure manual discharge summaries are to be completed within 7 days of discharge.
Client #1 was admitted on July 18, 2025 and was discharged on August 25, 2025. The discharge summary was due to be completed by September 01, 2025, however, one was not completed until September 24, 2025.
Client #7 was admitted on December 01, 2025 and was discharged on January 21, 2026. The discharge summary was due to be completed by January 28, 2026, however, one was not completed until February 08, 2026.
This is a repeat citation from both April 24, 2024 and March 11, 2025 annual licensing renewal 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, to include Discharge Summaries.
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 5/8/26. 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 or incorrect documentation for any active client will be updated within 1 week and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 5/8/26.
The Program Director will complete at least weekly 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 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 any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of 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 follow-up information, in two of three records reviewed. Per the facility's policy and procedure manual, follow-ups are to be completed within 30 days of discharge.
Client #1 was admitted on July 18, 2025 and was discharged on August 25, 2025. The client record did not contain documentation of follow-up information at the time of the inspection.
Client #7 was admitted on December 01, 2023 and was discharged on January 21, 2026. The client record did not contain documentation of follow-up information at the time of the inspection.
This is a repeat citation from April 27, 2022, June 03, 2023, April 24, 2024, and the March 11, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Post discharge follow-up will be completed correctly and in a timely manner for all clients.
Administrative Coordinator will complete Follow-Ups as per policy.
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 5/8/26. 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 or incorrect documentation for any active client will be updated within 1 week and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 5/8/26.
The Program Director will complete at least weekly 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 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 any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 correction that were approved by the Department.
A plan of correction for completing and documenting follow-up information for the outpatient records was submitted and approved by the Department for April 27, 2022, June 3, 2023, April 24, 2024, and March 11, 2025 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the April 01, 2026 licensing inspection.
A plan of correction for completing and documenting case consultations for the outpatient records were submitted and approved by the Department for April 24, 2024 and March 11, 2025 annual licensing inspections. Completed and documenting case consultations were again found to be a deficiency in the April 01, 2026 licensing inspection.
A plan of correction for completing discharge summaries was submitted and approved by the Department for April 24, 2024 and March 11, 2025 annual licensing inspection. Completing discharge summaries was again found to be a deficiency in the April 01, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area of the Plan of Correction.
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 Division 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. The first monthly meeting will occur on or before 5/8/2026. Any barriers noted will be addressed as appropriate.
The Division Director will report at least monthly to the Regional Clinical Director and Regional Executive 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 into full compliance.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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