INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 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 at Sunbury 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on May 14, 2025, the facility failed to ensure that hot water temperature may not exceed 120 degrees Fahrenheit.
When tested, the hot water in the employee bathroom was 123 degrees Fahrenheit.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On May 22nd, 2025, Facility Director submitted a maintenance request for the hot water temperature at the Sunbury Program. The request was to have the hot water temperature be lowered from 123 degrees Fahrenheit to 120 degrees Fahrenheit.
On May 30th, 2025, the maintenance ticket was closed indicating the temperature was lowered by 3 degrees as per the Assistant Maintenance Supervisor.
Quarterly physical plant inspections will occur by the Assistant Director of Maintenance. The inspection will include testing the temperature of the hot water at the location. Adjustments will be made as 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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of nine client records reviewed.
Client #2 was admitted on August 6, 2024, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #6 was admitted on November 27, 2024, and was discharged on April 2, 2025. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On June 23rd, 2025, during the weekly clinical meeting with counselors, the Clinical Supervisor will review confidentiality regulations related to the project shall obtain informed and voluntary consent from the client for the disclosure of information contained in the client record, which includes the funding source.
For client #2, the funding release was secured and placed in the record as of May 23rd, 2025.
Ongoing, during monthly chart audits, Clinical Supervisor will review the releases that are in the charts for accuracy. Any errors will be emailed to the counselor to correct during the next visit with the client.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or when know by facility, for ambulatory services.
On March 4, 2025, facility staff were informed about the passing of a client receiving treatment at the facility. A written unusual incident report was not filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On June 2nd, 2025, the Facility Director reviewed with the Clinical Supervisor that an incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or when known by facility for ambulatory services, an unusual incident report needs to be filed with DDAP within 3 business days of the incident.
For the missing UIR, the Facility Director will complete the report with the Department by June 17th, 2025. Ongoing, the Clinical Supervisor will notify the Facility Director within 24 hours of an incident or being made aware of an incident that may require the Department being notified. If a UIR is required, the Facility Director will notify the Department within required timeframe. |
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 the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of six applicable records reviewed.
Client #2 was admitted on August 6, 2024, and was a current client at the time of the licensing inspection. An updated treatment and rehabilitation plan was documented in the record on December 13, 2024, with the next updates due no later than February 13, 2025, and April 13, 2025; however, there were no updated treatment and rehabilitation plans documented in the client record at the time of the licensing inspection.
Client #5 was admitted on September 18, 2024, and was discharged on March 4, 2025. A comprehensive treatment and rehabilitation plan was documented in the record on October 9, 2024, with the updated treatment and rehabilitation plans due no later than December 9, 2024, and February 9, 2024; however, there were no updated treatment and rehabilitation plans documented in the client record at the time of the licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review requirements of Treatment Plan Updates being needed at least every 60 days during the clinical meeting on June 23rd, 2025.
For client #2- The TPU was completed as of 5/23/2025.
Ongoing, the Clinical Supervisor will provide a treatment plan analysis report weekly during clinical meetings to ensure staff are aware of upcoming treatment plan due dates.
Clinical Supervisor will monitor compliance during monthly chart audits. |
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 project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client #1 was admitted on August 14, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on September 13, 2024, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions documented in the client record for the months of October 2024 and December 2024.
Client #2 was admitted on August 6, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on August 5, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the months of December 2024 and April 2025.
Client #5 was admitted on September 18, 2024, and was discharged on March 4, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on October 9, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of October 20. 2024 through October 26, 2024, December 1, 2024 through December 7, 2024, December 15, 2024 through December 21, 2024, December 22, 2024 through December 28, 2024; and for the months of November 2024, January 2025, and February 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During the clinical meeting on June 23rd, 2025, the Clinical Supervisor will review that it is the counselor's responsibility to schedule/provide services according to the treatment plan.
For client #2, the individual was discharged on 5/30/2025. No further individual sessions needed.
During monthly chart audits completed by the Clinical Supervisor, review of services provided versus services indicated on treatment plan will be reviewed for compliance.
If there are discrepancies, the Clinical Supervisor will provide documented individual supervision to the counselor to discuss discrepancy and ensure compliance.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within three days of the date of service, per the facility's policy, in four of seven records reviewed.
Client #2 was admitted on August 6, 2024, and was a current client at the time of the licensing inspection. The record contained progress notes for counseling sessions occurring on August 15, 2024 that were not documented until October 1, 2024; session occurring on September 12, 2024 that was not documented until September 23, 2024; session occurring on September 24, 2024 that was not documented until October 1, 2024; session occurring on October 17, 2024 that was not documented until October 25, 2024; session occurring on October 24, 2024 that was not documented until November 4, 2024; session occurring on January 7, 2025 that was not documented until January 13, 2025; session occurring on January 16, 2025 that was not documented until January 27, 2025; and, session occurring on January 28, 2025 that was not documented until February 6, 2025.
Client #4 was admitted on June 3, 2024, and was discharged on August 26, 2024. The record contained progress notes for group counseling sessions occurring on June 3, 2024 that were not documented until July 8, 2024; session occurring on June 27, 2024 that was not documented until July 9, 2024; session occurring on July 11, 2024 that was not documented until August 5, 2024; session occurring on July 18, 2024 that was not documented until August 5, 2024; and, session occurring on July 25, 2024 that was not documented until August 5, 2024.
Client #5 was admitted on September 18, 2024, and was discharged on March 4, 2025. The record contained progress notes for counseling sessions occurring on October 1, 2024 that were not documented until October 7, 2024; session occurring on October 9, 2024 that was not documented until October 18, 2024; and, session occurring on October 15, 2024 that was not documented until October 25, 2024.
Client #6 was admitted on November 27, 2024, and was discharged on April 2, 2025. The record contained progress notes for counseling sessions occurring on December 5, 2024 that were not documented until December 18, 2024; session occurring on December 19, 2024 that was not documented until December 30, 2024; and, session occurring on February 6, 2025 that was not documented until February 17, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On June 23rd, 2025, during scheduled clinical meeting, the Clinical Supervisor will review the completion of notes immediately after the therapy session. Additionally, the Clinical Supervisor will be reviewing the counselors' schedules to ensure that each week time is scheduled for the completion of all notes by weeks end.
Ongoing, the Division Director will run a report reflecting note completion and will follow up with Clinical Supervisor on Monday afternoon that any outstanding notes will need to be completed by Tuesday
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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 a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes entered within 90 days of the date of service, per the facility's policy, in four of six applicable records reviewed.
Client #1 was admitted on August 14, 2024, and was a current client at the time of the licensing inspection. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #2 was admitted on August 6, 2024, and was a current client at the time of the licensing inspection. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #5 was admitted on September 18, 2024, and was discharged on March 4, 2025. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #7 was admitted on June 24, 2024, and was discharged on October 2, 2024. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During Clinical meeting on June 23rd, 2025, the Clinical Supervisor will review the workflow document with the counselors, this will include completing case consultations every 90 days unless the client's treatment is less then 90 days then one is completed.
The Clinical Supervisor will provide the CQI audit report during weekly clinical meetings which is a report that indicates completed case consultations as well as the due dates for upcoming case consultations. Counselor's will be expected to complete by the due date.
Ongoing compliance will be monitored through monthly chart audits that are completed by the Clinical Supervisor.
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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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include discharge summaries entered within seven days of the client ' s discharge, per the facility's policy, in three of four applicable records reviewed.
Client #4 was admitted on June 3, 2024, and was discharged on August 26, 2024. A discharge summary was not documented in the client record at the time of the inspection.
Client #5 was admitted on September 18, 2024, and was discharged on March 4, 2025. A discharge summary was not documented in the client record at the time of the inspection.
Client #6 was admitted on November 27, 2024, and was discharged on April 2, 2025. A discharge summary was not documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On June 23rd, 2025, 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.
For clients # 5 & 6, the discharge summaries will be completed no later than June 30th, 2025.
Clinical supervisor will monitor adherence to completion of discharge summaries by auditing 10% of all closed charts every month.
If any discharge summaries are missing, the supervisor will have the primary counselor complete it within 48 hours of notification.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information entered within 30 days of the client ' s discharge, per the facility's policy, in two of four applicable records reviewed.
Client #5 was admitted on September 18, 2024, and was discharged on March 4, 2025. Follow-up information was not documented in the client record at the time of the inspection.
Client #6 was admitted on November 27, 2024, and was discharged on April 2, 2025. Follow-up information was not documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During clinical meeting on June 23rd, 2025, Clinical Supervisor will advise clinical staff to block off time in their schedule each week to focus on completing discharge paperwork, which will include reviewing timelines of when a follow up contact note is due. It will be expected that during their blocked off time for discharge paperwork, completion of Follow Up contact form will occur.
Clinical supervisor will monitor adherence of the follow up contact note being completed by auditing 10% of all closed charts each month.
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