INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4, 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. Re-Entry House 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor met the educational qualifications for the position in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on December 9, 2024. The employee has an associate's degree with a major in liberal arts; however, a liberal arts college major is not a qualifying major in a related field.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
An exception request of 28 PA Code 704.7 (b) for the counselor identified was submitted on May 4, 2026 and accepted by the Department on May 12, 2026.
In the future, prior to hiring the position of counselor, the Program Director and Gaudenzia's Human Resource Department will ensure the applicant has the appropriate qualifications for the position. If there is any question, the Program Director and/or the Division Director will contact the Sr. Director of Regulatory Affairs and Compliance who will communicate with DDAP for guidance. If required, an exception request will be submitted, and the candidate will not begin in the position until the exception is approved.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records and the facility policy and procedure manual, the facility failed to ensure they maintained a mechanism to collect feedback on completed training, per their policy, in three of three applicable personnel records reviewed.
The facility policy and procedure manual stated "Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos, or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/Clinical Supervisor."
Employee # 2 was hired as the facility director on December 30, 2024. There were no training feedback forms documented, in the personnel record, for external trainings which were taken during the reviewed 2025 training year.
Employee # 3 was hired as a counselor on December 9, 2024. There were no training feedback forms documented, in the personnel record, for external trainings which were taken during the reviewed 2025 training year.
Employee # 5 was hired as a counselor on November 15, 2015. There were no training feedback forms documented, in the personnel record, for external trainings which were taken during the reviewed 2025 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia will collect feedback on all completed training. This will be done utilizing our training management system software. For training modules which are delivered via this system, feedback will be entered by the employee at the conclusion of the training. For training modules which are delivered via any external sources, the feedback will be entered by the employee at the time that the certificate is uploaded to the system.
The employee's direct supervisor will review the training transcript at least quarterly to ensure that all completed training and feedback is reflected.
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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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 a review of personnel records, the facility failed to ensure all staff persons received at least 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 within the regulatory time frame in two of five applicable personnel record reviewed.
Employee # 7 was hired as an administrative coordinator on January 23, 2006. The HIV/AIDS training and the TB/STD training was due to be completed no later than January 23, 2008; however, the documentation provided showed the HIV/AIDS training was completed on April 21, 2026 and the TB/STD training was completed on May 27, 2022.
Employee # 8 was hired as a recovery support professional on January 31, 2024. The HIV/AIDS training was due to be completed no later than January 31, 2026; however, the training was not completed as of the date of the inspection.
This is a repeat citation from the April 4, 2024 and May 16, 2025 annual licensing renewal inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe.
Outstanding training will be completed as soon as they can be scheduled. The HIV Training will be completed no later than 5/31/26 through the DDAP training system on-line demand session. The TB/STD/Hepatis training is anticipated to be no later than 6/30/26.
All staff member's Individual Training Plan has been updated in Gaudenzia's Training Management System to automatically assign the required trainings based on their position and employment start date. This is updated annually in January. The Training Plan and requirements are reviewed with all staff members and signed to indicate that they understand the training requirements.
The Program Director will review the Individual Training Plans monthly for all staff utilizing the reports in Gaudenzia's Training Management System. Staff who have upcoming training due dates within the next month will be reminded through email as well as during supervision.
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.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 facility's June 2025 through April 2026 fire drill logs, the facility failed to maintain their written fire drill logs included the documentation of the amount of time it took for evacuation and the number of persons in the facility at the time of the drill.
At the time of the inspection, the August 1, 2025 fire drill log did not include documentation of the amount of time it took for evacuation. Additionally, the April 29, 2026 fire drill log did not include documentation of the amount of time it took for evacuation and the number of persons in the facility at the time of the drill.
This is a repeat citation from the April 4, 2024 and May 16, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 5/31/26. This training will include a detailed review of the standard and all relevant Gaudenzia policies.
The Program Director will review each fire drill held and documented to ensure all the necessary components, including the time it took for the evacuation and the number of persons in the facility at the time of the drill is included in the fire drill log. If anything is missing, another fire drill will be held before the end of the month to ensure compliance.
The Division Director will review the fire drill log on a quarterly basis to ensure all documentation is found.
The Gaudenzia Compliance Department will conduct a review of the citation within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client records reviewed.
The policy and procedure manual stated that when a client is discharged against medical advice, the emergency contact will be called within twelve hours of the client leaving treatment.
Client # 5 was admitted on November 17, 2025 and was discharged against medical advice on January 13, 2026. There was no documentation in the record indicating that the emergency contact was notified of the client's discharge from treatment.
This is a repeat citation from the May 16, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review with staff during the next all staff meeting the requirements for notifying and documenting emergency contacts within 12 hours of a client leaving ASA .
The Program Director will review all client charts who are discharged ASA to ensure there is proper documentation in the chart reflecting the contact, or attempted contact made with the Emergency Contact if one is identified. All contacts will be documented in a Note to Chart.
Any ongoing issues in this area will be addressed and documented during individual supervision.
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.
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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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure is made to on consent to release information forms in three of seven client records reviewed.
Client # 1 was admitted on February 25, 2026 and was still active at the time of the inspection. The release of information forms to a parole officer and a case manager were signed by the client on February 25, 2026; however, both forms did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
Client # 2 was admitted on January 14, 2026 and was still active at the time of the inspection. The release of information forms to a parole officer and a case manager were signed by the client on January 14, 2026; however, both forms did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
Client # 3 was admitted on February 17, 2026 and was still active at the time of the inspection. The release of information forms to a parole officer and a case manager were signed by the client on February 17, 2026; however, both forms did not include documentation of the name of the person, agency, or organization to whom the disclosures would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The three client records identified in the deficiency (Client #1, #2, and #3) will have their release of information forms corrected to include the name of the person, agency, or organization to whom each disclosure is made. For any client who remains active in treatment, staff will obtain a corrected, fully completed consent form documenting the required recipient information. All corrections to the ROIs for the active clients listed will be completed within ten business days, and no later than 5/31/26. Should any of these clients no longer be in treatment at the time of correction, the facility will document that the client was discharged and the ROI cannot be updated.
Systemic Correction:
A consent to release information from the client for the disclosure of information contained in the client record will be completed fully, correctly, and in a timely manner to include the name of the person, agency, or organization to whom the disclosure is made.
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 5/31/26. This training will include a detailed review of the standard; all relevant policies; the specific areas of the clinical chart in which to document this information; and how to request assistance when needed.
The Program Director will complete at least weekly 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 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 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. |
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 an administrative review, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to maintain a written fire drill log, which is to include all the required information, was submitted and approved by the Department for the April 4, 2024 and May 16, 2025 annual licensing inspections. Failing to maintain a written fire drill log, including all the required information, was again found to be a deficiency in the May 4, 2026, licensing inspection.
A plan of correction for failing to ensure all staff persons received at least 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 within the regulatory time frame was submitted and approved by the Department for the April 4, 2024 and May 16, 2025 annual licensing inspections. Failing to ensure all staff persons received at least 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 within the regulatory time frame was again found to be a deficiency in the May 4, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area of the Plan of Correction.
Implementation will be monitored through at least monthly reviews of the Plan of Correction and documented follow up with any staff member found to be deviating from the action items listed.
The Division Director will meet with the Program Director at least monthly in documented supervision sessions to review and identify barriers to the implementation of each action item. Any barriers noted will be addressed as appropriate.
The Division Director will report at least monthly to the Regional Clinical Director and Regional Executive Director regarding any outstanding items, identified barriers, or other areas requiring improvement.
Any areas noted as not meeting the requirements listed above will be addressed with the Program Director in a documented supervision session note detailing any additional required actions to be taken to bring the program into full compliance.
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 |