INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 13, 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 Washington House 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records and administrative documents, the facility failed to maintain a mechanism to collect feedback on completed trainings in three of three applicable personnel records reviewed.
The facility policy and procedure manual stated each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos, or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/Clinical Supervisor.
Employee #2 was hired as the facility director on July 19, 2021 and was still in the position. There was no documentation of training feedback forms documented in the personnel record at the time of the inspection.
Employee #3 was hired as a counselor on January 22, 2019 and was still in the position. There was no documentation of training feedback forms documented in the personnel record at the time of the inspection.
Employee #4 was hired as a counselor on July 3, 2023 and was still in the position. There was no documentation of training feedback forms documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia will collect feedback on all completed trainings. This will be done utilizing our online training management system. For training modules which are delivered via the online training system, this feedback will be entered by the employee at the conclusion of the training. For training modules which are delivered via any external sources, the feedback will be entered by the employee at the time that the certificate is uploaded to the training management system.
The employee's direct supervisor will review the training transcript at least quarterly to ensure that all completed training and feedback is reflected.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to develop a written individual training plan annually with input from both the employee and supervisor in four of five personnel records reviewed.
The facility policy and procedure manual stated individual training plans are to be completed by the end of January each year.
Employee # 2 was hired as the facility director on July 19, 2021. Per the facility policy, the individual training plan was completed late, as it was completed on February 25, 2026.
Employee # 3 was hired as a counselor on January 22, 2019. Per the facility policy, the individual training plan was completed late, as it was completed on February 19, 2026.
Employee # 4 was hired as a counselor on July 3, 2023. Per the facility policy, the individual training plan was completed late, as it was completed on February 25, 2026.
Employee # 5 was hired as a counselor on April 21, 2025. Per the facility policy, the individual training plan was completed late, as it was completed on February 17, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Individual Training Plan (ITP) will be developed annually with input from both the employee and the supervisor, as specified in Gaudenzia Policy.
The Individual Training Plan will be finalized, signed by both employee and supervisor within the month of January of each calendar year.
The Program Director will utilize the Relias Training Platform to document each employee's training plan.
The Regional Clinical Director will review all Training Plans by January 15th of each year to ensure compliance. Any Training Plans not completed will be brought to the Program Directors attention. Once completed, the Program Director will inform the Regional Clinical Director.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on an administrative review of the July 2025 through March 2026 fire drill logs, the facility failed to ensure a fire alarm or smoke detector was set off for every fire drill conducted and documented during the reviewed period.
This is a repeat citation from the April 29, 2024 and May 7, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to the facility being co-located with another program and the expense of setting off an alarm, an exception was submitted and accepted by DDAP to not set off the fire or smoke alarm.
To meet this requirement, the program will conduct a fire drill by announcing a fire over the intercom. This will alert all staff, clients and guests to exit the building.
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 5/22/26. This training will include a detailed review of the standard and all relevant Gaudenzia policies.
The Program Director will review each fire drill monthly to ensure compliance with the regulation.
The Division Director will review each fire drill to ensure compliance. If the required procedure was not documented, another fire drill will occur during the month to ensure all regulations are followed and documented.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of three applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 6 was admitted on October 22, 2025 and was discharged against medical advice on December 11, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's discharge at the time of the inspection.
This is a repeat citation from the May 26, 2022, June 12, 2023, April 29, 2024, and May 7, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An ASA Standard Operating Procedure has been implemented since February 2026. A Review of the ASA Standard Operating Procedure will be reviewed with all staff by the Regional Clinical Director by 5/15/26.
The Regional Clinical Director will review all discharge information to include that the Emergency Contact is notified or attempts were made to notify them within 12 hours of an ASA if a release of information signed by the client has been completed. If the required documentation is not found, the clinician or designee will be required to complete this step immediately.
A Note to Chart will be written for all clients who ASA to include whether there is an appropriate release of information for an emergency contact and if there is, the contact or attempted contacts made with them.
The Gaudenzia Compliance Department will conduct a review of all POC citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations were reviewed and signed by the employee in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on January 22, 2019. The most recent annual written staff performance evaluation was completed on February 1, 2025; however, there was no documentation provided indicating the evaluation was reviewed and signed by the employee.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Annual Evaluations will be completed for all employees, and signed by the employee acknowledging the evaluation.
The Division Director will meet with all program management the month prior to the Performance Evaluations being due to ensure all program management understand the procedure for completing the Performance Evaluations along with the deadline to complete them.
Performance Evaluations will be completed and signed by the employee and supervisor utilizing the Human Resources Management system. The Supervisor will review the Performance Evaluation with the employee during supervision. The employee will add any additional comments to the evaluation, sign and submit the evaluation through Human Resource Management System. This employee never returned from employment since the date of the audit and is no longer working at Gaudenzia.
All staff files will be reviewed by Division Director during the month of April, to ensure all Performance Evaluations have been signed.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plans in three of six applicable records reviewed.
Client # 1 was admitted on January 26, 2026 and was still active at the time of the inspection. The individual treatment plan was completed on February 2, 2026 and treatment plan updates were completed on February 4, 2026, February 25, 2026, and March 3, 2026. All the treatment plans stated the client was to receive bi-weekly individual counseling sessions; however, there was no documentation in the record indicating individual sessions were provided during the month of February.
Client # 2 was admitted on February 3, 2026 and was still active at the time of the inspection. The individual treatment plan was completed on February 10, 2026 and treatment plan updates were completed on March 4, 2026 and March 23, 2026. All the treatment plans stated the client was to receive bi-weekly individual counseling sessions; however, there was documentation in the record indicating that the client was only provided one individual session on March 13, 2026.
Client # 3 was admitted on February 17, 2026 and was still active at the time of the inspection. The individual treatment plan was completed on February 26, 2026 and a treatment plan update was completed on March 26, 2026. Both treatment plans stated the client was to receive weekly individual counseling; however, however, there was no documentation in the record indicating individual sessions were offered to the client since March 12, 2026.
These findings were reviewed with facility staff during the licensing process.
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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 will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 5/15/26. The 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.
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.
The Gaudenzia Compliance Department will conduct a review of all POC citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of a discharge summary, in two of four applicable client records reviewed.
The facility policy and procedure manual stated discharge summaries are to be completed within seven days of discharge.
Client # 5 was admitted on December 17, 2025 and was discharged on January 22, 2026. The discharge summary was due to be completed no later than January 29, 2026; however, the summary was not completed until April 4, 2026.
Client # 7 was admitted on December 22, 2025 and was discharged on December 30, 2025. The discharge summary was due to be completed no later than January 6, 2026; however, the summary was not completed until March 28, 2026.
This is a repeat citation from the June 12, 2023, April 29, 2024, and May 7, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Clinical Director will review all discharge documentation requirements, including the Discharge Summary to be completed within 7 days with the Clinical Staff by 5/15/26.
The Regional Clinical Director will review all discharge information to include the Discharge Summary. The Detail of Discharges Report documents the date the discharge summary is completed and will be utilized by the Regional Clinical Director and Program Director to monitor for completeness minimally one time weekly.
An email will be sent to the clinician and Program Director for all discharge summaries that are due and follow -up will occur the next day.
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.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in three of four applicable client records reviewed.
The facility policy and procedure manual stated follow-up information is to be completed within seven days of discharge.
Client # 4 was admitted on October 22, 2025 and was discharged on January 22, 2026. The follow-up information was due to be completed no later than January 29, 2026; however, follow-up was not completed until March 31, 2026.
Client # 5 was admitted on December 17, 2025 and was discharged on January 22, 2026. The follow-up information was due to be completed no later than January 29, 2026; however, follow-up was not completed until April 4, 2026.
Client # 7 was admitted on December 22, 2025 and was discharged on December 30, 2025. The follow-up information was due to be completed no later than January 6, 2026; however, follow-up was not completed until March 31, 2026.
This is a repeat citation from the May 26, 2022 and June 12, 2023, April 29, 2024, and May 7, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Clinical Director will review all discharge documentation with the staff by 5/15/26. This review will include the need for a documented follow up with the client or program they are referred to based on Gaudenzia's policy and procedure.
The Regional Clinical Director will review all discharge information to include the client Follow-up. The Detail of Discharges Report documents the date the follow-up is completed and will be utilized by the Regional Clinical Director and Program Director to monitor for completeness.
Based on the Detail of Discharges report, the Regional Clinical Director will inform the staff of the need to complete the follow up and to document it on the Follow Up Contact Note in the client's chart. Any missing follow- up will be completed within 2 business days.
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.
The Gaudenzia Compliance Department will conduct a review of all 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 corrections that were approved by the Department.
A plan of correction for failing to notify an emergency contact within 12 hours after a client is discharged from the facility against medical advice was submitted and approved by the Department for the May 26, 2022, June 12, 2023, April 29, 2024, and May 7, 2025 annual licensing inspections. Failing to notify an emergency contact within 12 hours after a client is discharged from the facility against medical advice was again found to be a deficiency in the April 13, 2026 annual licensing inspection.
A plan of correction for failing to document a discharge summary, per facility policy, in the client record was submitted and approved by the Department for the June 12, 2023, April 29, 2024, and May 7, 2025 annual licensing inspections. Failing to document a discharge summary in the client record was again found to be a deficiency in the April 13, 2026, licensing inspection
A plan of correction for failing to document follow-up information, per facility policy, in the client record was submitted and approved by the Department for the May 26, 2022, June 12, 2023, April 29, 2024, and May 7, 2025 annual licensing inspections. Failing to document follow-up information in the client record was again found to be a deficiency in the Apri 13, 2026 licensing inspection.
A plan of correction for failing to set off a fire alarm or smoke detector for every fire drill conducted was submitted and approved by the Department for the April 29, 2024 and May 7, 2025 annual licensing inspections. Failing to set off a fire alarm or smoke detector for every fire drill conducted was again found to be a deficiency in the Apri 13, 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 to full compliance.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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