INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 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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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 a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #3 was admitted on October 03, 2024 and was discharged on February 4, 2025. A comprehensive treatment plan was completed on November 15, 2024, and an update was due no later than January 15, 2025; however, none was documented.
Client #4 was admitted on June 18, 2024 and was discharged on October 9, 2024. A comprehensive treatment plan was completed on June 18, 2024, and an update was due no later than August 18, 2024; however, none was documented.
Client #7 was admitted on August 13, 2024 and was still active at the time of the inspection. A treatment plan update was completed on October 28, 2024, and the next update was due no later than December 28, 2024; however, none was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical meeting on May 14th, 2025 the Clinical Supervisor will review the workflow document that includes the timeline of when a Treatment Plan Update needs to be completed.
Ongoing, the Clinical Supervisor will provide a treatment plan analysis report to the clinicians during bi-weekly clinical meetings that indicates upcoming treatment plan updates that are due.
Monitoring of these items being completed will be documented during monthly chart audits. |
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 policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, per facility policy, in seven of seven records reviewed.
Client #1 was admitted on August 08, 2024 and was still active at the time of the inspection. The record contained a progress note for an individual session occurring on August 08, 2024, August 15, 2024, November 26, 2024, and January 21, 2025, that was not completed until August 19, 2024, August 23, 2024, December 5, 2024, and January 27, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on September 17, 2024, October 8, 2024, December 10, 2024, and January 21, 2025, that was not completed until September 25, 2024, October 16, December 16, 2024, January 27, 2025, respectively.
Client # 2 was admitted on September 16, 2024 and was still active at the time of the inspection. The record contained progress notes for individual group session notes occurring on November 06, 2024, November 27, 2024, December 16, 2024, December 31, 2025, and February 4, 2025; that were not completed until November 18, 2024, December 05, 2024, April 03, 2025, and January 07, 2025, and February 10, 2025, respectively.
Client # 3 was admitted on October 03, 2024 and was discharged on February 4, 2025. The record contained progress notes for an individual session that occurred on November 27, 2024, that were not completed until December 4, 2024. Additionally, the record contained progress notes for group sessions occurring on November 06, 2024, November 08, 2024, and January 21, 2025; that were not completed until November 18, 2024, November 18, 2024, and January 27, 2025, respectively.
Client #4 was admitted on June 18, 2024 and was discharged on October 9, 2024. The record contained progress notes for individual sessions occurring on July 9, 2024, August 08, 2024, and August 21, 2024; that were not completed until July 15, 2024, August 19, 2024, and August 29, 2024, respectively. Additionally, the record contained progress notes for group sessions occurring on July 24, 2024, and August 15, 2024; that were not completed until August 2, 2024, and August 23, 2024, respectively.
Client #5 was admitted on October 03, 2024 and was discharged on March 6, 2025. The record contained progress notes for individual sessions occurring on November 05, 2024, and December 10, 2024; that were not completed until November 12, 2024, and December 10, 2024, respectively. Additionally, the record contained progress notes for group sessions occurring November 6, 2024, December 10, 2024, December 31, 2024, and January 21, 2025; that were not completed until November 18, 2024, December 16, 2024, January 7, 2025, and January 27, 2025, respectively.
Client #6 was admitted on July 2, 2024 and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on September 17, 2024, October 08, 2024, November 05, 2024, and December 31, 2024; that were not completed until September 25, 2024, October 16, 2024, November 12, 2024, and January 7, 2025. respectively.
Client #7 was admitted on August 13, 2024 and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on August 8, 2024, and February 14, 2025; that were not completed until August 19, 2024, and February 21, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring August 21, 2024, and October 9, 2024; that were not completed until August 29, 2024, and October 17, 2024, respectively.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 21, 2023, and April 09, 2024 licensing inspection.
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Plan of Correction
On May 14th, 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. |
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 the review of client records, the facility failed to document case consultations within the timeframe established by the facility ' s policy and procedure manual in seven out of seven applicable client records. The facility's policy and procedure manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed.
Client #1 was admitted on August 08, 2024 and was still active at the time of the inspection. The first case consultation was due no later than November 8, 2024; however, one was not completed until April 7, 2025.
Client #2 was admitted on September 16, 2024 and was still active at the time of the inspection. The first case consultation note was due no later than December 16, 2024; however, it was not completed until April 3, 2025.
Client # 3 was admitted on October 03, 2024 and was discharged on February 4, 2024. The client record did not contain documentation of case consultation notes.
Client #4 was admitted on June 18, 2024 and was discharged on October 9, 2024. The client record did not contain documentation of case consultation notes.
Client # 5 was admitted on October 03, 2024 and was discharged on March 06, 2025. The first case consultation note was due no later than January 03, 2025; however, it was not completed until March 06, 2025.
Client #6 was admitted on July 02, 2024, and was still active at the time of the inspection. The first case consultation note was due no later than October 2, 2024; however, it was not completed until March 25, 2025.
Client #7 was admitted on August 13, 2024, and was still active at the time of the inspection. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 21, 2023 and April 9, 2024 licensing inspection.
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Plan of Correction
During Clinical meeting on May 14th, 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 each clinical meeting 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 and/or Division Director. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan in one out of one applicable record.
Client #3 was admitted on October 3, 2024 and discharged on February 4, 2025. There was no documentation of an aftercare plan in the client record.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
During the clinical meeting on May 14th, 2025, the clinical supervisor will review the workflow document that indicates when a continuing care plan is to be started and completed (aftercare plan).
The clinical supervisor will monitor adherence to this form being completed by auditing 25% of closed charts for the next 90 days.
The clinical supervisor will use direct supervision to review any missing documents that are found during chart audits. The supervision will allow the program to make an individual plan of correction, if needed. |
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, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in one of three applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #4 was admitted on June 18, 2024 and discharged on October 09, 2024. A discharge summary was due no later than October 16, 2024; however, there is no documentation that one was completed.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 21, 2023, and April 9, 2024 licensing inspection.
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Plan of Correction
On May 14th, 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.
Clinical supervisor will monitor adherence to completion of discharge summaries by auditing 25% of all closed charts for that month for the next 90 days.
If concerns continue to exist, Clinical Supervisor will work with identified counselor(s) during supervision to develop an individual plan of correction.
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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 a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting discharge summaries in the outpatient records was submitted and approved by the Department for the June 21, 2023, and April 09, 2024, annual licensing inspections. Completing and documenting discharge summaries was again found to be a deficiency in the April 11, 2025, licensing inspection.
A plan of correction for completing and documenting case consultations for the outpatient records was submitted and approved by the Department for the June 21, 2023, and April 09, 2024, annual licensing inspection. Completing and documenting case consultations was again found to be a deficiency in the April 11, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 14th, 2025 and occurring on a monthly basis, the Division Director will participate in a scheduled Clinical Meeting for this location. The Division Director will review the current POCs that are in place with the staff and also review the chart audits for the current month. This will allow the Division Director to follow through on current POCs. Any deficiencies will be reviewed with Clinical Supervisor the same day of the meeting and follow up with documentation will be requested. This will continue throughout the year.
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