INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 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 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, the facility failed to ensure that the clinical supervisor met the educational qualifications for the position.
Employee #3 was hired as a counselor on November 6, 2017, and was promoted to Clinical Supervisor on April 01, 2025. The employee did not have a qualifying degree for the position at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All candidates for any position will be reviewed to ensure that they meet all requirements prior to beginning in the position. When there is any uncertainty, this will be discussed, and when appropriate, an exception may be submitted. The Candidate will not begin in the position until an approved exception is documented.
In this specific case, an exception request has been submitted on 3/30/27.
We are awaiting a reply. In the meantime, the Program Director and Regional Clinical Director are reviewing and signing all documents that require a clinical supervisor's signature.
Employee #3 will apply for her CADC by 5/15/26 and schedule/complete test by 6/15/26.
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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 client records, the facility failed to obtain consent to release information form prior to releasing information in one out of fourteen records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #2 was admitted to the outpatient level of care on August 04, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for disclosure of information contained in the client record was signed and dated August 25, 2025, for a funding source.
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 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.
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.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of partial hospitalization client records, the project failed to document two weekly individual counseling sessions in four of seven partial hospitalization clients reviewed.
Client #8 was admitted on June 16, 2025 and stepped down to the outpatient level of care on July 03, 2025. The project only documented one individual counseling session for the weeks of June 16, 2025 through June 21, 2025, and June 22, 2025 through June 28, 2025.
Client #10 was admitted on February 25, 2026 and still was active at the time of the inspection. The project only documented one individual counseling session for the week of March 15, 2026 through March 21, 2026.
Client #12 was admitted on March 02, 2026 and stepped down to the outpatient level of care on March 20, 2026. The project only documented one individual counseling session for the week of March 08, 2026 through March 14, 2026.
Client #14 was admitted on February 04, 2026 and was successfully discharged on February 25, 2026. The project did not document any individual counseling sessions for the week of February 08, 2026 through February 14, 2026.
This is a repeat citation from April 02, 2025 annual licensing inspection.
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Plan of Correction
Treatment services will be delivered in accordance with all relevant regulations and the Treatment Plan.
The Scheduling Calendar in our EHR system will be utilized in order to ensure that this occurs as required. This will be monitored by the Program Director on a weekly basis and any issues noted will be immediately brought to the attention of the clinician for remedy.
This requirement was reviewed with all appropriate staff members in a documented in-service training on 4/20/2026. This training included 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 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 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.
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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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of outpatient client records, the facility failed to document that a comprehensive treatment plan was developed with the client and within guidelines established by the facility's policy and procedures manual in three out of seven records reviewed. The facility ' s policy and procedures manual states that the comprehensive treatment plan is completed within thirty days of admission.
Client #1 was admitted on September 25, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 06, 2025; however, there is no documentation that the comprehensive treatment plan was completed with the client.
Client #2 was admitted on August 04, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 29, 2025; however, there is no documentation that the comprehensive treatment plan was completed with the client.
Client #7 was admitted on September 30, 2025, and was discharged on March 16, 2026. A comprehensive treatment plan was due to be completed by October 30, 2025; however, it was not completed until November 07, 2025; However, there is no documentation that is was completed with client.
This is a repeat citation from April 18, 2024 and April 02, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans will be completed correctly and in a timely manner. If a client is not available, or is a no-show for the session during which the Treatment Plan is scheduled to be completed/updated, this will be documented in a note to chart, and a draft Treatment Plan completed by the clinician. This draft will be reviewed, updated, and signed by the client upon their next visit, prior to receiving any additional services to ensure that no services are provided without a valid treatment plan in effect.
This requirement will be reviewed with all appropriate staff members in a documented in-service training 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, the Regional Clinical 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 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of six applicable records reviewed.
Client # 1 was admitted on September 25, 2025 and still was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 06, 2025, and the treatment plan update was due no later than December 06, 2026; however, there was no documented treatment updates at the time of the inspection.
Client #2 was admitted on August 04, 2025 and still was active at the time of the inspection. The treatment plan update was dated December 22, 2025, and the next update was due to be completed by February 22, 2026; however, it was not completed until March 12, 2026.
Client #5 was admitted on July 03, 2025 and still was active at the time of the inspection. The treatment plan update was completed on September 22, 2025, and the next update was due to be completed by November 22, 2025; however, there was no documented treatment plan updates at the time of the inspection.
Client #6 was admitted on September 05, 2025 and was discharged to a higher level of care on January 20, 2026. The treatment plan update was completed on November 07, 2025, and the next update was due to be completed by January 07, 2026; however, the treatment plan update was incomplete at the time of the inspection.
Client #7 was admitted on September 30, 2025 and was discharged on March 16, 2026. The treatment plan update dated December 22, 2025, was not completed at the time of the inspection. Additionally, there were not additional treatment plans completed at the time of the inspection.
This is a repeat citation from March 28, 2022, May 12, 2023, April 18, 2024, and the April 02, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans will be completed correctly and in a timely manner. If a client is not available, or is a no-show for the session during which the Treatment Plan is scheduled to be completed/updated, this will be documented in a note to chart, and a draft Treatment Plan completed by the clinician. This draft will be reviewed, updated, and signed by the client upon their next visit, prior to receiving any additional services to ensure that no services are provided without a valid treatment plan in effect.
This requirement will be reviewed with all appropriate staff members in a documented in-service training 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, the Regional Clinical 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 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 four records reviewed. The facility's policy and procedure manual states follow ups will be completed within 7 days of discharge.
Client #3 was admitted on August 19, 2025 and was adminstratively discharged on September 11, 2025. The client record did not contain documentation of follow-up information.
Client #6 was admitted on September 05, 2025 and was discharged on January 20, 2026. The follow up was not documented until March 13, 2026.
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 Coordinators will complete follow-ups in a correct and 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 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 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.
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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 treatment plan updates in the outpatient records was submitted and approved by the Department for the March 28, 2022, May 12, 2023,April 18, 2024, and April 02, 2025 annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the March 27, 2026 licensing inspection.
A plan of correction for completing and documenting treatment plans developed with the client in the outpatient records was submitted and approved by the department for the April 18, 2024 and April 02, 2025 annual licensing inspections. Completing and documenting treatment plans developed with the client was again found to be a deficiency in the March 27, 2026 licensing inspection.
These findings were 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. 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.
All of these action steps will be fully implemented no later than 5/8/26
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