This report is a result of an off-site complaint investigation conducted July 7, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the investigation, Gaudenzia, Inc. Re-Entry House, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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Observations
Based on a review of unusual incident reports, the facility failed to inform the Department of a client death within three days following the incident.
A community concern unusual incident report was submitted on June 22, 2026 regarding a client falling, hitting their head, and being taken to the hospital by EMS. The client death was reported by the client's insurance to this Department on July 2, 2026, not by the facility.
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Plan of Correction
All future reports will be submitted by the Program Director via the Electronic Reporting System (ERS) within 3 business days.
All internal incident reports will be submitted by program staff to the Program Director within 24 hours of the incident to make the determination as to whether the incident is of a type which would be classified as an Unusual Incident per 709.34.
As an added reminder, an automated alert email is sent to the Program Director by our internal reporting system when an incident submitted is of a type which may require an Unusual Incident Report to DDAP.
For any incident involving a client death the Compliance department will confirm with the Program Director that an Unusual Incident report has been submitted to DDAP.
The Gaudenzia Compliance Department will conduct a review of all action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed. |