INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 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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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of client records and discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of ambulance personnel on March 28, 2025, and October 10, 2024; however, there was no documentation that written unusual incident reports were ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The report in question will be submitted by the Program Director via the Electronic Reporting System (ERS) no later than 6/16/25.
All future reports will be submitted via by the Program Director the Electronic Reporting System (ERS) within 3 business days.
All internal incident reports will be submitted to the Program Director within 24 hours of the incident to make the determination as to whether the incident is of a type which would be classified as an Unusual Incident per 709.34.
The Division Director will meet with the Program Director at least monthly in documented supervision sessions which will include review of incident reports during that time period as well confirmation of any required eternal reporting. Any which were not reported to DDAP will be reported immediately.
The Division Director will report at least monthly to the Deputy Director regarding any issues in this area, identified barriers, or other areas requiring improvement.
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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, 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 within 30 days of discharge, per facility policy, in two of four applicable records reviewed.
Client # 2 was admitted on December 17, 2024 and was discharged on April 11, 2025. The follow-up information was not documented until May 20, 2025.
Client # 4 was admitted on October 23, 2024 and was discharged on February 4, 2025. The client record did not contain documentation of follow-up information.
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. 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 6/20/25. 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 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 6/20/25.
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.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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