INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 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 Outpatient 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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709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment and rehabilitation plans in two out of five applicable records reviewed.
Client #1 was admitted on March 17, 2025 and was still active at the time of the inspection. The treatment plan dated March 20, 2025, did not have documentation of proposed type of supportive services.
Client #4 was admitted on February 6, 2025 and was discharged on February 21, 2025. The treatment plan dated February 11, 2025, did not have documentation proposed type of supportive services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical meeting on 5/5 Program Director will review with clinical staff all aspects of treatment plans including supportive services. Program Director will have the counselor of Client #1 correct the treatment plan to reflect supportive services by 5/15. Ongoing when reviewing documents for signature Clinical Supervisor will review treatment plans for accuracy and reject those that don't meet the minimum standard for including supportive services. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services on a regular and scheduled basis to include individual counseling at least twice weekly in three out of seven records reviewed.
Client #3 was admitted on March 14, 2025 and was still active at the time of the inspection. There was one documented individual session the week of March 17, 2025 and no documented individual sessions the week of March 24, 2025.
Client #5 was admitted on February 24, 2025 and was discharged to a lower level of care on March 13, 2025. There was one documented individual session the weeks of February 24 and March 3, 2025.
Client #6 was admitted on July 10, 2024 and discharged to a lower level of care on July 26, 2024. There were no documented individual sessions the week of July 15, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Monday 5/5 Clinical Supervisor will review weekly with Partial counselor that every Partial client will have 2 individual sessions weekly. Partial counselor will document scheduled sessions. Missed sessions and attempts to reschedule will also be documented. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan completed with the client within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within thirty days of admission.
Client #11 was admitted to the outpatient level of care on November 8, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 8, 2024; however, there was no documentation of it being completed at the time of the inspection.
Client #13 was admitted to the outpatient level of care on May 16, 2024 and discharged on September 25, 2024. A comprehensive treatment plan was completed on June 10, 2024; however, there is no documentation that the plan was developed with the client.
This is a repeat citation from the April 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 12th, 2025, the Program Director will review with counselors the policy of completing treatment plans with the client within 30 days of admission.
Ongoing, the Clinical Supervisor will present the Treatment Plan Analysis report during weekly clinical meetings, so the counselors are aware of treatment plans that are due.
The Clinical Supervisor will monitor the completion of Comprehensive Treatment Plans through monthly chart audits. |
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 document treatment plan updates within the regulatory timeframe in three out of three applicable records reviewed.
Client #10 was admitted to the outpatient level of care on July 26, 2024 and was still active at the time of the inspection. A treatment plan was completed on July 31, 2024, and the next update was due no later than September 29, 2024; however, it was not completed until October 3, 2024.
Client #11 was admitted to the outpatient level of care on November 8, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 9, 2025, and the next update was due no later than March 10, 2025; however, it was not completed until March 11, 2025.
Client #13 was admitted to the outpatient level of care on May 16, 2024 and discharged on September 25, 2024. A treatment plan was completed on June 10, 2024, and the next update was due no later than August 9, 2024; however, it was not completed until August 12, 2024.
This is a repeat citation from the March 28, 2022, May 12, 2023 and April 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/5 Program Director will review with the counselors the policy of completing treatment plan updates with the client within 60 days of the comprehensive treatment plan. Ongoing, the Clinical supervisor will print out the treatment plan analysis report and review in weekly clinical meetings for compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the facility ' s policy and procedures manual of every ninety days in two out of four applicable client records.
Client #10 was admitted to the outpatient level of care on July 26, 2024 and was still active at the time of the inspection. A case consultation was due no later than October 26, 2024; however, there is no documentation that one was completed.
Client #11 was admitted to the outpatient level of care on November 8, 2024 and was still active at the time of the inspection. A case consultation was due no later than February 8, 2025; however, there is no documentation that one was completed.
This is a repeat citation from the May 12, 2023 and April 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/5 Program Director will review with the counselors the policy of completing case consults every 90 days from day of admission. Client number 11 has been discharged. Ongoing, Clinical Supervisor will run Clinical Forms Audit weekly and inform counselors of required documents needed or missing specifically Case Consults. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in four out of four applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #8 was admitted on February 24, 2025 and discharged on March 24, 2025. A discharge summary was due no later than March 31, 2025; however, there is no documentation that one was completed.
Client #12 was admitted on June 17, 2024 and discharged on August 13, 2024. A discharge summary was due no later than August 20, 2024; however, there is no documentation that one was completed.
Client #13 was admitted on May 16, 2024 and discharged on September 25, 2024. A discharge summary was due no later than October 2, 2024; however, there is no documentation that one was completed.
Client #14 was admitted on October 10, 2024 and discharged on November 15, 2024. A discharge summary was due no later than November 22, 2024, however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/5/25, the Clinical Supervisor will meet with the counselors and review the policy of completing a Discharge Summary within 7 days of discharge from the program.
Clinical supervisor will monitor adherence to completion of discharge summaries by auditing 10% of all closed charts for 90 days. |
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 correction that were approved by the Department.
A plan of correction for completing and documenting treatment plan updates in the outpatient records was submitted and approved by the Department for the March 28, 2022, May 12, 2023, and April 18, 2024 annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the April 2, 2025 licensing inspection.
A plan of correction for completing and documenting case consultations for the outpatient records was submitted and approved by the Department for the May 12, 2023 and April 18, 2024 annual licensing inspection. Completing and documenting case consultations was again found to be a deficiency in the April 2, 2025 licensing inspection.
This is a repeat citation from the April 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 5, 2025 and occurring monthly, the Program Director will participate in a scheduled Clinical Meeting for this location. The Program Director will review the current POCs that are in place with the staff and review the chart audits for the current month. This will allow the Program Director to follow through on current POCs. Any deficiencies will be reviewed with Clinical Supervisor the same day of the meeting and follow up with documentation will be requested. This will continue throughout the year. |