INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-13, 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, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure staff received at least 6 hours of HIV/AIDS and 4 hours of TB/STD within the first two years of employment in one of one applicable records.
Staff #1 was hired at the facility August 5, 2019 and still employed at time of inspection. Communicable disease training was due no later than August 5, 2021. There was no documentation provided for the completion of the trainings as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe.
The outstanding trainings for this individual will be completed as soon as they can be scheduled. This is anticipated to be no later than 12/31/26.
All staff members have an Individual Training Plan generated on their start
date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Gaudenzia Compliance Department will conduct a review of all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans within 30 days in four of six client records.
Client #2 admitted February 18, 2026 and discharged May 11, 2026. A treatment plan was completed on March 20, 2026 and an update was due by April 19, 2026 but not completed until April 25, 2026.
Client #3 admitted February 18, 2026 and discharged April 24, 2026. A treatment plan was completed on March 20, 2026 and an update was due by April 19, 2026 but not completed prior to discharge.
Client #6 admitted May 19, 2026 and still a current client. A treatment plan was completed on June 18, 2026 and an update was due by July 18, 2026 but not completed prior to inspection.
Client #7 admitted May 27, 2026 and still a current client. A treatment plan was completed on June 26, 2026 and an update was due by July 26, 2026 but not completed prior to inspection.
This finding was 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.
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
10/9/26. 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 with the
required information including the frequency of treatment and rehabilitation services prior to signing the Treatment Plan. If any information is missing, the Treatment Plan will be rejected, and the clinician will complete an updated Treatment Plan for review.
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.
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.
The Gaudenzia Compliance Department will conduct a review of all POC action
items within 90 days to ensure full implementation, identify any barriers to
implementation, and coordinate support, where needed.
Responsible Parties:
- Clinicians
- Clinical Supervisor
- Program Director
- Division Director
- Regional Clinical
Director
- Regional Executive
Director
- Quality Assurance
Manager
- Compliance Department
Staff
Target Completion Date: 10/9/2026 |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to complete case consultations in four of six applicable records.
Per agency policy and procedures, case consultations are to be completed within 15 days of admission and every 90 days thereafter.
There were no case consultations documented in the following client records.
Client #3 admitted February 18, 2026 and discharged April 24, 2026.
Client #5 admitted April 14, 2026 and discharged July 14, 2026.
Client #6 admitted May 19, 2026 and still a current client.
Client #7 admitted May 27, 2026 and still a current client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The primary counselor will be responsible for documenting a case
consultation note after meeting with the multidisciplinary team at least once every 90 days or sooner if clinically indicated (i.e., reviewing information obtained at admission, updating clinically relevant changes or return to substance use, progress or lack
thereof with treatment goals, change in status, etc.). The case consultation note will be routed to and signed off by all parties who participated and/or were present during the consultation.
Counselors will utilize the program's documentation checklist and CQI department's documentation timeframes form to ensure all treatment services and administrative tasks are delivered and documented in a timely manner. Counselors will submit the checklist to the Clinical Supervisor to assist with monitoring documentation quality and compliance adherence. Clinical Supervisor will ensure receipt of the checklists within 7 days of a client's admission and discharge.
During the weekly client chart review process, the case consultation note will be added to the review to monitor
compliance with documentation of case consultation notes.
Program Director will utilize a tracking sheet to record which clients are reviewed during case consultation meetings. This tracker will be shared with the Clinical Supervisor to monitor
compliance and timely documentation and for reference to follow up with counselors as needed. If the Program Director is not present during the consultation, the Clinical Supervisor will assume responsibility for using the tracking form.
Clinical Supervisor and/or Program Director will provide supervision and/or progressive discipline when necessary to
ensure compliance with licensing requirements.
Responsible Parties:
- Clinicians
- Clinical Supervisor
- Program Director
- Division Director
- Regional Clinical
Director
- Regional Executive
Director
- Quality Assurance
Manager
- Compliance Department
Staff
Target Completion Date: 9/15/2026 and ongoing |