INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 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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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, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in five out of five applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #1 was admitted on September 12, 2025 and was still active at the time of the inspection. There was no documentation in the client record of case consultation notes being completed at the time of the inspection.
Client #2 was admitted on admitted on July 26, 2025 and was still active at the time of the inspection. There was no documentation in the client record of case consultation notes being completed at the time of the inspection.
Client #3 was admitted on October 24, 2025 and was still active at the time of the inspection. There was no documentation in the client record of case consultation notes being completed at the time of the inspection.
Client #6 was admitted on November 28, 2025 and discharged on April 17, 2026. There was no documentation in the client record of case consultation notes being completed at the time of the inspection.
Client #7 was admitted on August 11, 2025 and discharged on February 03, 2026. A case consultation note was completed on September 23, 2025, and the next one was due to be completed by December 23, 2025; however, none was completed at the time of the inspection.
This is a repeat citation from April 11, 2025, April 9, 2024 and June 21, 2023 annual licensing 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 5/29/26. 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)(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 document discharge summary information within guidelines established by the facility's policy and procedures manual in two out of four applicable records reviewed. The facility's policy and procedures manual states that discharge summary information must be completed within 7 days of discharge.
Client #4 was admitted on June 27, 2025 and discharged on August 20, 2025. There was no documentation for a discharge summary being completed at the time of the inspection.
Client #6 was admitted on November 28, 2025 and was discharged on April 17, 2026. There was no documentation for a discharge summary being completed at the time of the inspection
This is a repeat citation from April 11, 2025, April 9, 2024 and June 21, 2023 annual licensing 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 a Discharge Summary for all discharged 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 5/29/26. 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 5/22/26.
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.
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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709.17(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, April 09, 2024, and April 11, 2025 annual licensing inspections. Completing and documenting discharge summaries was again found to be a deficiency in the April 27, 2026, 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, April 09, 2024, and April 11, 2025 annual licensing inspection. Completing and documenting case consultations was again found to be a deficiency in the April 27, 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
This process will be implemented for the month of May 2026 and documented no later then 5/29/2026.
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