INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-13, 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. 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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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a review of the facilities physical plant, the facility failed to ensure frozen foods were kept at or below 0 degrees Fahrenheit.
The freezer located in the kitchen had a thermometer reading of 4 degrees Fahrenheit. The freezer located in the dining room had a thermometer reading of 10 degrees Fahrenheit. The freezer located in the basement had a thermometer reading of 2 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director contacted the Maintenance department to schedule a service call for the freezers. In the meantime, the freezer temperatures will be monitored at least daily and if they rise significantly above 0 degrees, food will not be stored in those freezers until repaired. Going forward, the Program Director will monitor monthly temperatures during Monthly facility inspections and notify maintenance of any continued concerns. The repair man will be here to look at all freezers by 9/30/25 He will be here sooner if temps go above 0 degrees We moved gauges from the door and set them further back in the freezer to get an accurate reading |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills once a month.
Reviewed fire drills from August 2024 to July 2025. No fire drills were conducted from August 2024 through January 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Fire drills will be completed monthly for each shift as per DDAP regulations. Fire drills have been completed monthly since a new Director was hired and will continue to be done monthly as required by DDAP. The fire drills will be documented, and uploaded into the organization's SharePoint system, to ensure visibility and oversight by senior management. Any issues noted will be addressed in supervision. The Director of the Snow House will work with a RSP to ensure monthly fire drills and documentation
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in three of three applicable client records.
There was no documentation of the facility notifying the client of the decision to terminate treatment in the following client records.
Client #3 was admitted on March 12, 2025 and involuntarily terminated on June 19, 2025.
Client #4 was admitted on April 25, 2025 and involuntarily terminated on June 30, 2025.
Client #5 was admitted on April 18, 2025 and involuntarily terminated on July 12, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director will facilitate a review during the next staff meeting of the procedures for notifying clients of involuntary discharge. This will occur no later than 9/24/25
Going forward, the Program Director will monitor compliance during monthly chart audits of discharged charts. Any concerns will be addressed in a documented clinical supervision session with responsible staff members.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident.
The facility had unusual incidents occur on February 10, May 4, and August 10, 2025 all which involved police or EMS personnel onsite and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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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 to the Program Director within 24 hours of the incident to make the determination as to whether the incident is of the type which would be classified as an Unusual Incident per 709.34.
The Regional Executive Director will meet with the Program Director at least monthly in documented supervision sessions which will include review of incident reports during that time as well as confirmation of any required external reporting, and any issues / identified barriers/or other areas requiring improvement. Any which were not reported to DDAP will be reported immediately.
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