INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12, 2026, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee # 5 was hired as a counselor on November 11, 2024 and was due to have the HIV/AIDS training and the TB/STD training completed no later than November 11, 2025. There was documentation that the HIV/AIDS training was completed timely, but the TB/STD training was completed on December 31, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe.
In-Service with Director and Supervisor will occur on or before June 5th,2026 to review required training for new hires and timeline of completion.
All staff members have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Supervisor will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion.
The Clinical Supervisor and Program Director will review the Individual Training Plans weekly for new hires, and at least quarterly for all staff. Staff who have upcoming training due dates within the next quarter will be reminded of this and the Supervisor will work with them to schedule training sessions prior to the due dates and will monitor to ensure full and timely completion.
If any issues are noted with staff failing to complete scheduled trainings, this will be specifically addressed with them in a documented supervision session with a clear plan to have all trainings completed.
If any issues are noted with unavailability of required training session opportunities, this will be addressed with the Division Director and the Regional Executive Director to assist in advocating with the training provider.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document a psychosocial evaluation, during the intake and admission process, in three of seven client records reviewed.
The facility policy and procedure manual stated psychosocial evaluations will be completed within 30 days after admission.
Client # 1 was admitted on December 22, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by January 22, 2026; however, the evaluation was not completed until March 26, 2026.
Client # 2 was admitted on November 7, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by December 7, 2025; however, there was no evaluation documented in the record at the time of inspection.
Client # 6 was admitted on August 25, 2025 and was discharged on November 4, 2025. There was a psychosocial evaluation uploaded into the electronic client record on August 25, 2025; however, the evaluation was blank.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Psychosocial evaluation will be contained in the client record for all clients and will be completed fully, correctly, and in a timely manner.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/15/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support where needed.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed types of support services on the individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 3 was admitted on October 13, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on October 20, 2025; however, there were no proposed types of support services documented on the plan.
Client # 7 was admitted on September 22, 2025 and was discharged on November 14, 2025. The individual treatment plan was completed on October 1, 2025; however, there were no proposed types of support services documented on the plan.
This is a repeat citation from the May 15, 2025 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The proposed type of support services will be documented within all client's treatment plans.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/15/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the specific areas of the treatment plan in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/7/26.
The Clinical Supervisor will review all treatment plans for clinical soundness and completeness as evidenced by their signature, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 maintain a complete client record, which is to include documentation of case consultation notes, in three of six applicable records reviewed.
The facility policy and procedure manual indicated that case consultation notes will be completed at least every 90 days.
Client # 2 was admitted on November 7, 2025 and was active at the time of inspection. A case consultation note was due by February 7, 2026; however, there was documentation that two case consultation notes were completed on May 11, 2026.
Client # 3 was admitted on October 13, 2025 and was active at the time of inspection. There were no case consultation notes documented in the record as of the date of the inspection.
Client # 4 was admitted on October 21, 2025 and was discharged on March 12, 2026. There were no case consultation notes documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner to include Case Consultation Notes.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/15/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Regional Clinical Director in regular supervision sessions, and any barriers to implementation addressed at that time.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 maintain a complete client record, which is to include documentation of follow-up information, in three of four applicable records reviewed.
The facility policy and procedure manual stated follow-up information will be completed within 30 days of discharge.
Client # 4 was admitted on October 21, 2025 and was discharged on March 12, 2026. The documentation of follow-up information was due to be completed by November 21, 2025, but it was not documented in the record until May 8, 2026.
Client # 5 was admitted on November 20, 2025 and was discharged on December 29, 2025. The documentation of follow-up information was due to be completed by January 29, 2026, but it was not documented in the record until May 8, 2026.
Client # 6 was admitted on August 25, 2025 and was discharged on November 4, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
This is a repeat citation from the May 15, 2025 annual licensing renewal inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Post discharge follow-up will be completed correctly and in a timely manner for all clients.
This requirement will be reviewed with all appropriate staff members in a documented in-service training within the next two weeks, and no later than 6/15/26. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
Any missing or incorrect documentation for any active client will be updated within 1 week and reviewed by the Clinical Supervisor to ensure that it is accurate and comprehensive. This will be completed no later than 6/7/26.
The Clinical Supervisor will complete at least weekly reviews, the Program Director will complete at least monthly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor or Program Director with the clinician responsible in a documented supervision session and corrected within 48 hours.
The Gaudenzia Compliance Department will conduct a review of any repeat citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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