INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 06, 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 Common Ground 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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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of fourteen records reviewed.
Client #5 was admitted to the detoxification level of care on June 14, 2025 and discharged on June 23, 2025. There was no consent to release information form for the funding source, or to a family member. Facility staff confirmed billing had occurred, and per a contact note, information had been disclosed to the family member on June 25, 2025.
Client #9 was admitted to the inpatient hospital level of care on January 30, 2026, and still was active at the time of the inspection. There was no consent to release form for a family member, per a family session progress note, dated March 19, 2026, family member attended family session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An informed and voluntary consent from the client for the disclosure of information contained in the client record 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 5/22/26. 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.
Any missing releases for any active client will be updated within 1 week and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 5/15/26.
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 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 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client's record in one out of fourteen client records reviewed.
Client #1 was admitted to the detoxification level of care on April 02, 2026, and was still active at the time of the inspection. A consent form signed and dated April 02, 2026, for the funder, a family member, and an outside clinic, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A consent to release of information from the client for the disclosure of information contained in the client record 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 5/22/26. 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 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 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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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of detox 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 five out of five applicable records. The facility's policy and procedures manual states that a discharge summary is completed within seven days of discharge.
Client #3 was admitted May 14, 2025 and was discharged on May 17, 2025. A discharge summary was due no later than May 24, 2025; however, there was no documentation that one was completed.
Client #4 was admitted on July 11, 2025 and was discharged on July 16, 2025. A discharge summary was due no later than July 23, 2025; however, there was no documentation that one was completed.
Client #5 was admitted on June 14, 2025 and was discharged on June 23, 2025. A discharge summary was due no later than June 30, 2025; however, there was no documentation that one was completed.
Client #6 was admitted on July 08, 2025 and was discharged on July 13, 2025. A discharge summary was due no later than July 20, 2025; however, there was no documentation that one was completed.
Client #7 was admitted on August 11, 2025 and was discharged on August 16, 2025. A discharge summary was due no later than August 23, 2025; however, there was no documentation that one was completed.
This is a repeat citation from May 06, 2025 annual licensing inspection.
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Plan of Correction
A consent to release of information from the client for the disclosure of information contained in the client record 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 5/22/26. 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 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 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of rehabilitation client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within 3 days of admission, in three of seven applicable records reviewed.
Client #9 was admitted on January 30, 2026 and still active at the time of the inspection. The psychosocial was due to be completed by February 02, 2026; however, it was not completed until February 04, 2026.
Client #10 was admitted on February 05, 2026 and was active at the time of the inspection. The psychosocial was due to be completed by February 08, 2026; however, it was not completed until February 09, 2026. .
Client #14 was admitted on February 26, 2026 and was active at the time of the inspection. The psychosocial was due to be completed by March 01, 2026; however, it was not completed until March 04, 2026.
These findings were discussed 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 5/22/26. 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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709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 recordsand the facility's policy and procedure manual, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary, in two out of three applicable records reviewed. The facility's policy and procedure manual states discharge summaries are to be completed within 7 days of discharge.
Client #11 was admitted on August 08, 2025 and discharged on August 15, 2025. The client record did not contain documentation of a discharge summary at the time of the inspection.
Client #13 was admitted on September 17, 2025 and discharged on November 19, 2025. The discharge summary was due to be completed by November 26, 2025, however; the discharge summary was completed December 22, 2025.
This is a repeat citation from May 06, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Discharge Summary will be contained in the client record for all discharged 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 5/22/26. 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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