INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28, 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 Inc. Harrisburg Concept 90 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(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 provide a written individual training plan for each employee, appropriate to that employee's skill level per the facility ' s policy and procedure manual in four out of five employee records reviewed. The facility ' s policy and procedure manual states that the individual training plan is due by the end of January.
Employee #2 was hired on January 1, 2022 as the facility director and was still in the position as of the date of the inspection. The individual training plan was not completed until March 10, 2025.
Employee #3 was hired on July 12, 2023 as a clinical supervisor and was still in the position as of the date of the inspection. The individual training plan was not completed until March 1, 2025.
Employee #4 was hired on January 2, 2019 as a counselor and was still employed at the time of the inspection. The individual training plan was not completed until February 27, 2025.
Employee #5 was hired on August 7, 2023 as a counselor and was still employed at the time of the inspection. The individual training plan was not completed until March 4, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will work with Clinical Supervisor and RSP Supervisor to assure all training plans for staff are completed by January 31.
Program Director will work with Clinical Supervisor and RSP Supervisor to assure all new hires receive and review their training plan within the first 7 days of hire. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection on April 28, 2025, the facility failed to ensure that all food was stored off the floor.
In the room labeled " Cook " , which consisted of the cook ' s office and food storage, there were boxes of food found sitting on the floor.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director reviewed safe storage of food with the new cook. The cook has rearranged storage spaces to assure no food is left on floor.
Program Director will conduct biweekly survey of the office to assure compliance. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher located on the second floor near the conference room did not have an inspection tag attached therefore there is no documentation that it was inspected.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On 4/28 Maintenance was notified of missing tag on fire extinguisher. On 4/29 a representative from Kint Fire Extinguishing department arrived and place a tag on the stated fire extinguisher.
The RSP Safety Representative will conduct monthly extinguisher checks and report to the Program Director any deficiencies with extinguisher tags and pressure gauges.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the May 2024 through February 2025 fire drill logs during the inspection, the facility failed to document what exit was used during the evacuation for the August 29, 2024, and the January 12, 2025, fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed with RSP team how to complete the Fire Evacuation Reports on 5/6/25, The RSP Supervisor/Program Director will review evacuation forms on a monthly basis to assure they are completed correctly. |
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 the review of client records, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in one out of one applicable record reviewed.
Client #5 was admitted on September 23, 2024 and left against medical advice on October 29, 2024. There was no documentation that the emergency contact was notified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Supervisor will review discharges and assure Emergency Contact is called per policy. |
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 per the facility ' s policy and procedure manual in two out of five personnel records reviewed. The facility ' s policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee #4 was hired on January 2, 2019 as a counselor and was still employed at the time of the inspection. The annual work performance evaluation was completed on February 10, 2025.
Employee #5 was hired on August 7, 2023 as a counselor and was still employed at the time of the inspection. The annual work performance was not completed until February 10, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will work with Clinical Supervisor and RSP Supervisor to assure all staff evaluations are completed per policy. |
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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #1 was admitted on January 30, 2025 and was still active at the time of the inspection. There was documentation that the facility made contact with a funding source on March 14, 2025, and contact with a drug and alcohol facility on March 27, 2025; however, there was no documentation that the facility obtained an informed and voluntary consent for the funding source or drug and alcohol facility.
This is a repeat citation from the May 24, 2023 and May 23, 2024 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant and RSPs will have client sign consents upon admission. Additional consents will be completed by the Clinical Team prior to making contacts for after care.
The Clinical and RSP Supervisors will review charts to assure releases are completed on day of admission and prior to aftercare contacts.
The Clinical Supervisor will review all current charts to assure all current clients have updated ROI(s). |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility ' s policy and procedure manual and the physical plant inspection on April 28, 2025, the drug storage areas and medications shall be inspected by an assigned nurse or designated trained staff member at least quarterly. The facility ' s policy and procedure manual states the nurse or designated trained staff member will make quarterly inspection of all drug storage units to include emergency equipment and medical supplies. These areas are maintained in compliance with Federal, State and local regulations. The facility did not have documentation of quarterly inspections of the drug area or medications.
This is a repeat citation from the May 23, 2024 licensing inspections.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Nurse will be responsible for completing the quarterly review. The Program Director will sign off on the quarterly audits. |
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 the clients received counseling services according to their individual treatment and rehabilitation plan in three out of seven records reviewed.
Client #2 was admitted on March 26, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan dated March 29, 2025, indicated one individual session a week. There was no documentation of the client receiving individual therapy the week of April 21, 2025.
Client #4 was admitted on August 23, 2024 and discharged on September 30, 2024. The individual treatment and rehabilitation plan dated August 26, 2024, indicated weekly individual sessions. There was no documentation that the client received individual sessions the week of September 23, 2024.
Client #5 was admitted on September 23, 2024 and discharged on October 29, 2024. The individual treatment and rehabilitation plan dated September 24, 2024, indicated one individual session a week. There was no documentation that the client received individual therapy the weeks of October 14 and 21, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will assure members are being seen weekly with weekly audits.
The Clinical Supervisor will assign other clinical staff to see clients when primary counselor is out for a week or more. |
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 provide a complete client record, which is to include case consultation in three out of seven applicable discharged records reviewed. The facility ' s policy and procedures manual states that case consult occurs within fifteen days and then every ninety days thereafter.
Client #2 was admitted on March 26, 2025 and was still active at the time of the inspection. A case consultation was due no later than April 10, 2025; however, it was completed on April 27, 2025.
Client #5 was admitted on September 23, 2024 and discharged on October 29, 2024. A case consultation was due no later than October 8, 2024; however, it was completed on October 17, 2024.
Client #7 was admitted on January 24, 2025 and discharged on March 6, 2025. 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 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct biweekly chart audits to assure case consults are completed by due date. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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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 aftercare information in three out of seven records reviewed. The facility ' s policy and procedures manual states that aftercare documentation starts at the day of admission and finalized at discharge.
Client #2 was admitted on March 26, 2025 and was still active at the time of the inspection. An aftercare form was due to be started on March 26, 2025; however, there is no documentation that one was started.
Client #3 was admitted on March 25, 2025 and was still active at the time of the inspection. An aftercare form was due to be started on March 25, 2025; however, there is no documentation that one was started.
Client#7 was admitted on January 24, 2025 and discharged on March 6, 2025. There was no documentation that aftercare was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review with clinical team the process for completing After Care plans at time of admission and discharge.
The Clinical Supervisor will assure documentation is completed through regular audits. |
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 provide a complete client record, which is to include a discharge summary in two out of four applicable discharged records reviewed. The facility ' s policy and procedures manual states that discharge summaries are completed within seven days of discharge.
Client #5 was admitted on September 23, 2024 and discharged on October 29, 2024. A discharge summary was due no later than November 5, 2024; however, it was completed on November 26, 2024.
Client #7 was admitted on January 24, 2025 and discharged on March 6, 2025. A discharge summary was due no later than March 13, 2025; 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
The Clinical Supervisor will review with clinical team the process for completing discharge summaries within 7 days of discharge.
The Clinical Supervisor will assure documentation is completed through regular audits. |
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 provide a complete client record, which is to include follow-up information in three out of four applicable discharged records reviewed. The facility ' s policy and procedure manual states that follow up contacts occur within seven days.
Client #5 was admitted on September 23, 2024 and discharged on October 29, 2024. A follow up was due no later than November 5, 2024; however, it was completed on December 6, 2024.
Client #6 was admitted on October 31, 2024 and discharged on November 25, 2024. A follow up was due no later than December 2, 2024; however, it was completed on December 6, 2024.
Client #7 was admitted on January 24, 2025 and discharged on March 6, 2025. A follow up was due no later than March 13, 2025; however, it was completed on March 17, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has reviewed the regulations regarding Follow Up contacts with Administrative Assistant.
The Program Director and Clinical Supervisor will conduct monthly chart audits of D/C clients to assure FU contacts are completed per policy. |
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 obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the May 24, 2023, and May 23, 2024, annual licensing inspections. Obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was again found to be a deficiency in the April 28, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review all plans of corrections monthly to ensure compliance.
This will be supported by Gaudenzia's CQI team who will conduct quarterly audits.
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