INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-13, 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 a review of personnel records, the facility failed to ensure staff received at least 6 hours of HIV/AIDS and 4 hours of TB/STD within the first two years of employment in one of one applicable records.
Staff #1 was hired at the facility August 5, 2019 and still employed at time of inspection. Communicable disease training was due no later than August 5, 2021. There was no documentation provided for the completion of the trainings as of the date of the inspection.
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.
The outstanding trainings for this individual will be completed as soon as they can be scheduled. This is anticipated to be no later than 12/31/26.
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 Gaudenzia Compliance Department will conduct a review of all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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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 of fourteen records.
Client #11 admitted to the residential level of care February 4, 2026 and discharged March 11, 2026. Disclosure was confirmed to a state agency on March 10, 2026 but no valid consent to release information was documented in the client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project shall obtain an informed and voluntary
consent from the client for the disclosure of information
contained in the client record.
This requirement will be reviewed with all appropriate staff members in a documented in-service training no later than 9/25/26. 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 9/18/26.
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 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 all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
- Clinical Staff
- Clinical Supervisor
- Program Director
- Division Director
- Regional Executive Director
- Quality Assurance Manager
- Compliance Department Staff 9/25/26
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of four applicable client records.
There were no documented termination letters in the following client records.
Client #1 admitted to the detoxification level of care January 4, 2026 and administratively discharged on January 7, 2026.
Client #2 admitted to the detoxification level of care May 12, 2026 and administratively discharged on May 26, 2026.
This finding was 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 notifying the client in writing the reason for an involuntary termination utilizing the form created for this purpose in our EHR.
This requirement will be reviewed with all appropriate staff members in a documented in-service training no later than 9/25/26. 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 review all clients' charts who are involuntarily terminated to ensure the client was notified in writing the reason for involuntary termination.
The Program Director will conduct monthly reviews of clients who are involuntarily terminated from treatment.
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 POC action steps within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans within 30 days in three of six client records.
Client #10 admitted to the residential level of care June 14, 2026 and still a current client. A treatment plan was completed on June 16, 2026 and an update was due by July 16, 2026 but not completed until July 22, 2026.
Client #13 admitted to the residential level of care June 9, 2026 and discharged July 16, 2026. A treatment plan was completed on June 15, 2026 and an update was due by July 15, 2026 but not completed prior to discharge.
Client #15 admitted to the residential level of care January 10, 2026 and discharged March 18, 2026. A treatment plan was completed on January 12, 2026 and an update was due by February 11, 2026 but not completed until February 18, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.52. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
All Treatment Plans 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 9/25/26. 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 ensure all Treatment Plans are completed with the required information including the frequency of treatment and rehabilitation services prior to signing the Treatment Plan. If any information is missing, the Treatment Plan will be rejected, and the clinician will complete an updated Treatment Plan for review.
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 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 all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
· Clinicians
· Clinical Supervisor
· Program Director
· Division Director
· Regional Clinical Director
· Regional Executive Director
· Quality Assurance Manager
· Compliance Department Staff
9/25/26
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