INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 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. Outreach 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 the facility policy and procedure manual, the facility failed to ensure they maintained a mechanism to collect feedback on completed training, per their policy, in one of one 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 # 5 was hired as a counselor on November 23, 2024. There was no training feedback form documented for an external training in their personnel record.
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 training management system. For training modules which are delivered via the training management 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. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) 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 each fire drill.
At the time of the inspection, there was no documentation provided indicating a fire alarm or smoke detector was set off during the July 11, 2025, August 1, 2025, August 22, 2025, September 9, 2025, September 26, 2025, October 10, 2025, November 28, 2205, December 15, 2025, December 22, 2025, March 4, 2026, and March 16, 2026 fire drills.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
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 5/29/26. This training will include a detailed review of the standard to include documenting a fire alarm or smoke detector is set off for the drill and all relevant Gaudenzia policies. The Clinical Supervisor will review each fire drill held and documented to ensure all of the necessary components, including setting off a fire alarm or smoke detector, is included in the fire drill log. If the documentation does not include whether a fire alarm or smoke detector is set off for the drill, the Clinical Supervisor will conduct another drill for the month to ensure the drill is completed by utilizing a fire alarm or smoke detector for the drill. The clinical supervisor will document this appropriately on the fire drill log. The Division Director will review the fire drill log on a quarterly basis to ensure all documentation is found. The Gaudenzia Compliance Department will conduct a review of the citation within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.
Client # 1 was admitted on October 23, 2025 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 3 was admitted on September 24, 2025 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 6 was admitted on November 28, 2025 and was discharged on April 17, 2026. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the May 21, 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 obtaining a consent to release information prior to disclosing any client information. 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 5/29/26. 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 Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 5/29/26. 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 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. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.
Client # 5 was admitted on December 30, 2025 and was administratively discharged on January 14, 2026. There was no documentation in the record indicating the client was provided with written notification of the facility's decision to involuntarily terminate treatment at the project.
This is a repeat citation from the May 21, 2025 annual licensing renewal inspection.
This finding was 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 notifying the client in writing the reason for an involuntary termination.
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 5/29/26. 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.
The Clinical Supervisor will review all clients' charts who are involuntarily terminated to ensure the client was notified in writing the reason for involuntary termination.
The Program Director will conduct monthly reviews of clients who are involuntarily terminated from treatment.
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 the plan of correction within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
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 client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of five applicable client records reviewed.
Client # 1 was admitted on October 23, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 23, 2025 and an update was due no later than December 23, 2025; however, the update was not completed until January 8, 2026. Additionally, a treatment plan update was completed on February 5, 2026 and another update was due no later than April 5, 2026; however, the update was not completed until April 23, 2026.
Client # 2 was admitted on December 29, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 29, 2025 and an update was due no later than February 27, 2026 however, the update was not completed until March 27, 2026.
Client # 3 was admitted on September 24, 2025 and was still active at the time of the inspection. A treatment plan update was completed on November 13, 2025 and an update was due no later than January 13, 2026; However, the update was not completed until January 22, 2026.
Client # 6 was admitted on November 28, 2025 and was discharged on April 17, 2026. A treatment plan update was completed on January 6, 2026 and an update was due no later than March 6, 2026; However, the update was not completed prior to discharge.
Client # 7 was admitted on September 17, 2025 and was discharged on March 16, 2026. The individual treatment and rehabilitation plan was completed on September 17, 2025 and an update was due no later than November 17, 2025; However, the update was not completed until December 8, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Treatment Plans in the client record will be completed fully, correctly, and in a timely manner to include updating the treatment plan in accordance with Gaudenzia's policy.
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. The treatment plan 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 within the next two weeks, and no later than 5/29/26. 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.
The Clinical Supervisor will ensure all Treatment Plans are completed within the required timeframe, or that a Note to Chart is written to identify why the treatment plan could not be updated as required.
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 the presence, timeliness and quality of each chart document.
The Gaudenzia Compliance Department will conduct a review of the plan of correction 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. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 assure counseling services were being provided to the client according to the individual treatment and rehabilitation plan in four of six applicable client records reviewed.
Client # 1 was admitted on October 23, 2025 and was still active at the time of the inspection. The individual treatment plan and update, completed on October 23, 2025 and January 8, 2026, indicated the client was to receive one individual therapy session per week. The record of service and progress notes indicated that the client received individual sessions every other week in the months of December 2025 and January 2026.
Client # 2 was admitted on December 29, 2025 and was still active at the time of the inspection. The individual treatment plan, completed on December 29, 2025 indicated the client was to receive one individual therapy session per week. The record of service and progress notes indicated that the client received one session in January 2026 and no sessions in February 2026.
Client # 3 was admitted on September 24, 2025 and was still active at the time of the inspection. The treatment plan updates, completed on January 26, 2026 and March 12, 2026 indicated the client was to receive one group therapy session per week. The record of service and progress notes indicated that the client has not received any group counseling sessions since January 27, 2026.
Client # 7 was admitted on September 17, 2025 and was discharged on March 16, 2026. The individual treatment and rehabilitation plans and the treatment plan updates, completed on September 17, 2025, December 8, 2025, and February 9, 2026 indicated the client was to receive two individual therapy session per week. The record of service and progress notes indicated that the client received three individual sessions in October, 2025, 2 individual sessions in November 2025, 2 individual sessions in December 2025, 1 individual session in January 2026, 2 individual sessions in February 2026 and 2 individual sessions in March 2026.
This is a repeat citation from the June 23, 2023, May 16, 2024, and May 21, 2025 annual licensing renewal inspections.
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 to include assuring counseling services are provided according to the individual 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 Clinical Supervisor 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 5/29/26. 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.
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 the plan of correction within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
709.93(a)(6) 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:
(6) Individual treatment and rehabilitation plan.
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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 case consultation notes, in three of six applicable client records reviewed.
Client # 1 was admitted on October 23, 2025 and was still active at the time of the inspection. There was no case consultation notes documented in the records at the time of the inspection.
Client # 2 was admitted on December 29, 2025 and was still active at the time of the inspection. There was no case consultation notes documented in the records at the time of the inspection.
Client # 7 was admitted on September 17, 2025 and was discharged on March 16, 2026. There was no case consultation notes documented in the records at the time of the inspection.
This is a repeat citation from the October 1, 2020, June 22, 2021, June 15, 2022, June 23, 2023, May 16, 2024, and May 21, 2025 annual licensing renewal inspections.
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 5/29/26. 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.
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 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 |
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 an administrative review, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure case consultation notes were documented in the client record was submitted and approved by the Department for the October 1, 2020, June 22, 2021, June 15, 2022, June 23, 2023, May 16, 2024, and May 21, 2025 annual licensing inspections. Failing to include case consultation notes in the client record was again found to be a deficiency in the April 30, 2026, licensing inspection.
A plan of correction for failing to assure counseling sessions are provided according to the individual treatment and rehabilitation plan was submitted and approved by the Department for the June 23, 2023, May 16, 2024, and May 21, 2025 annual licensing inspections. Failing to assure that counseling sessions are provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the April 30, 2026, annual 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.
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.
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. |