INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 3, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gaudenzia Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of employee records, the facility failed to provide supervision of a counselor assistant by a full-time clinical supervisor or counselor.
Employee # 4 was hired on February 10, 2025, and worked as a counselor assistant from May 15, 2025, through December 17, 2025. There are no supervisory sessions documented in the employee file during this time.
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Plan of Correction
Counselor Assistants will be supervised by the Clinical Supervisor. The Clinical Supervisor will document the supervisory note immediately following the supervisory session. This time will be blocked off on the Clinical Supervisors Outlook Calendar when the supervisory session is scheduled.
If the Clinical Supervisor is not available to conduct the supervision, the Program Director or a counselor who meets the qualifications in 704.6 or 704.7 will conduct and document the supervision.
The Program Director will review documented supervisory notes during their supervision with the Clinical Supervisor to ensure they are completed.
The Director of Audits and Monitoring will complete a review of the written POC within 3 months. If a Counselor Assistant is on staff, documentation of supervisory sessions will be reviewed to ensure the documentation is complete. This review will be shared with program management, and any issues noted will be addressed immediately. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of employee records, the facility failed to provide a written semiannual performance evaluation based upon measurable performance standards.
Employee # 4 was hired on February 10, 2025, and worked as a counselor assistant from May 15, 2025, through December 17, 2025. There was no semiannual performance evaluation documented in the employee file during this time.
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Plan of Correction
The Program Director will work with the Clinical Supervisor to ensure that Counselor Assistants receive a semiannual performance evaluation based upon measurable performance standards.
Gaudenzia's Human Resource software generates a reminder to the Clinical Supervisor to complete a performance evaluation for a Counselor Assistant after 5 months of employment.
The Clinical Supervisor will complete the performance evaluation and review with the counselor assistant before the 6 semi-annual due date.
The Director of Audits and Monitoring will complete a review of the written POC within 3 months. If a Counselor Assistant is on staff and has been in the position for 6 months, documentation of a performance evaluation will be reviewed to ensure the documentation is complete. This review will be shared with program management, and any issues noted will be addressed immediately.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the Individual Treatment and Rehabilitation Plan policy, the facility failed to follow its written procedures for documenting the comprehensive treatment plan in one of five records reviewed.
Per the Individual Treatment and Rehabilitation Plan policy, the comprehensive treatment plan is due within 7 days of admission.
Client # 4 was admitted on January 13, 2026, and was still an active participant at the time of the investigation. The comprehensive treatment plan should have been completed no later than January 20, 2026; however, it was dated January 27, 2026.
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Plan of Correction
All clinical staff participated in a mandatory meeting on 2/4/26 to review the requirement of developing a comprehensive treatment plan with the client within 7 days of admission.
The Clinical Supervisor will run the scorecard report from our EHR each morning, which indicates if and when a comprehensive treatment plan is completed, and will send a reminder email to clinical staff regarding all upcoming treatment plans.
If the Scorecard Report indicates a treatment plan is late, the clinician will meet with the client to develop one within 24 hours.
The Clinical Supervisor will discuss any ongoing issues with treatment plan timeframes during individual documented supervision with the clinician.
The Director of Audits and Monitoring will complete a review of the written POC within 3 months to ensure all treatment plans include the frequency of treatment and rehabilitation services specifically for Group services. This review will be shared with program
management and followed up on by the Clinical Supervisor with staff as necessary. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services on an individual treatment and rehabilitation plan in two of five records reviewed.
Client # 2 was admitted on January 20, 2026, and was still an active participant at the time of the investigation. The individual treatment and rehabilitation plan dated January 27, 2026, did not have the frequency of group services documented.
Client # 5 was admitted on January 23 ,2026, and was still an active participant at the time of the investigation. The individual treatment and rehabilitation plan dated January 27, 2026, did not have the frequency of group services documented.
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Plan of Correction
All clinical staff (including Counselors and other relevant personnel) participated in a mandatory clinical meeting to review the requirement of including type and frequency of treatment and rehabilitation services within the client's treatment plan on 2/4/26.
The Clinical Supervisor will review all treatment plans prior to approving and ensure that each treatment plan includes the type and frequency of treatment and rehabilitation services particularly for group services. If the treatment plan does not contain this information, the treatment plan will be rejected, and the clinician will be required to update the plan with the client and re-submit it for review by the clinician supervisor within 48 hours. The Clinical Supervisor will discuss any ongoing issues during individual supervision with the clinician.
Director of Audits and Monitoring will complete a review of the written POC within 3 months to ensure all treatment plans include the frequency of treatment and rehabilitation services specifically for Group services. This review will be shared with program management and followed up on by the Clinical Supervisor with staff as necessary. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include progress notes, in one of five records reviewed.
Client # 2 was admitted on January 20, 2026, and was still an active participant at the time of the investigation. The record did not contain documentation of an individual progress note.
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Plan of Correction
All clinical staff participated in a mandatory clinical meeting on 2/4/26 to review the facility's progress note completion timelines.
This meeting specifically covered:
A comprehensive review of the organization's policy regarding progress note documentation.
Strategies for effective time management and prioritization of charting responsibilities to ensure timely and accurate recordkeeping.
All clinical staff who have been employed for less than 6 months and those that are not completing individual progress notes in a timely manner must route their notes to the Clinical Supervisor. The Clinical Supervisor tracks the individual notes as well as other important documentation, utilizing an excel spreadsheet.
If documentation is not submitted within the required timeframes, the Clinical Supervisor will meet with the clinician during a supervisory session to review the missing documentation. The clinician will complete the documentation within 48 hours.
The Director of Audits and Monitoring will complete a review of the written POC within 3 months to ensure all progress note documentation is completed correctly and accurately. This review will be shared with program management and followed up on by the clinical supervisor with staff as necessary.
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