INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 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 Focus 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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704.11(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 that one of three employees received a minimum of four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 3 has been in the position of recovery support staff since February 1, 2021 and was due to have the communicable disease trainings no later than February 1, 2023. There was documentation that the employee only received two training hours of TB/STD at the time of the inspection.
This is a repeat citation from the May 30, 2024 and May 18, 2023 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member in question was assigned 4 hours of TB training in Relias Learning. Training completed on Relias
Certificates verifying training were completed on 6/4/2025.
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 Supervisor will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, four months of staff schedules and the Staffing Requirement Facility Summary Report (SRFSR), the project failed to ensure that at least a sufficient number of staff persons trained in CPR and first aid was onsite during the project's hours of operation.
The facility ' s hours of operation are 24 hours a day, 7 days a week. There were no staff members with a current CPR/First Aid Certificate between the hours of 11:00PM and 7:00AM, for the following dates: March 16, 2025, March 17, 2025, March 19, 2025, March 21, 2025, March 22, 2025, March 23, 2025, March 24, 2025, March 25, 2025, March 26, 2025, March 27, 2025, March 30, 2025, April 1, 2025, April 2, 2025, April 4, 2025, April 5, 2025, April 6, 2025, April 8, 2025, April 9, 2025, April 10, 2025, April 12, 2025, April 13, 2025, April 14, 2025, April 17, 2025, April 18, 2025, April 19, 2025, April 20, 2025, April 21, 2025, April 23, 2025, April 24, 2025, April 25, 2025, April 28, 2025, April 29, 2025, April 30, 2025, May 1, 2025, May 3, 2025, May 5, 2025, May 6, 2025, May 8, 2025, May 9, 2025, May 10, 2025, May 11, 2025, May 12, 2025, May 13, 2025, May 14, 2025, May 15, 2025, May 19, 2025, May 20, 2025 and May 21, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff member in question was assigned to complete CPR/FA with National CPR Foundation on 5/22/2025
Certificates verifying training was completed on 5/22/2025.
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 Supervisor will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion.
Certificates of completion as well as Evaluations will be maintained in the staff file.
The Clinical Supervisor and Program Director will review the Individual Training Plans weekly for new hires, and at least quarterly for all staff. Staff who have upcoming training due dates within the next quarter will be reminded of this and the Supervisor will work with them to schedule training sessions prior to the due dates and will monitor to ensure full and timely completion.
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.
If any issues are noted with unavailability of required training session opportunities, this will be addressed with the Division Director and the Deputy Director to assist in advocating with the training provider.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The thermometer inside the basement freezer read 5 degrees Fahrenheit.
This is a repeat citation from the May 30, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This condition was immediately addressed by staff to ensure the health and safety of everyone at the site.
Staff will conduct a daily check of the walk-in freezer door to ensure that ice does builds up, preventing the door from closing properly.
This issue will be monitored during regular health and safety checks.
The Program Director will review the health and safety reports at least monthly to ensure that this is being regularly monitored and that any issues noted are being reported to the Maintenance department via additional work orders.
Any barriers to having this fully corrected will be brought to the attention of the Division Director and Deputy Director to address directly with the Maintenance department head.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill log from June 2024 through April 2025, the facility failed to prepare alternate exit routes to be used during fire drills.
The same exit was documented during each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia Focus House will ensure the use of varied exit routes to be used during fire drills. This will be documented on the standard Fire Drill Grid.
Program Supervisor will specify which exits to be used during each monthly fire drill.Program Supervisor will review fire drill logs monthly to ensure that this is being implemented.
If there are any issues noted, another round of Fire Drills will be conducted following all requirements.
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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 two of two applicable records reviewed.
Client #3 was admitted to the inpatient non-hospital transitional living level of care on January 28, 2025 and was discharged Against Staff Advice (AMA) on May 12, 2025. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
Client #4 was admitted to the inpatient non-hospital transitional living level of care on July 25, 2024 and was discharged Against Staff Advice (AMA) on September 4, 2024. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
This is a repeat citation from the May 30, 2024 and May 18, 2023 annual licensing renewal inspections.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
All clients' Emergency Contact persons will be notified within 12 hours of an ASA discharge of a client.
Program Supervisor created a emergency contact list with members name and their emergency contact name and contact number.
Program Supervisor provided the emergency contact list to the entire Focus House staff and reviewed the policy with staff members on June 6, 2025.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in two of seven records reviewed.
Client #2 was admitted on October 4, 2024 and was active at the time of the inspection. A release of information form, signed by the client on October 3, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.
Client #5 was admitted on October 8, 2024 and was discharged December 2, 2024. A release of information form, signed by the client on October 8, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All consent forms will be fully and correctly completed, including the name of the specific person or entity to whom disclosure is to be 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 6/6/2025. 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 6/6/2025.
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in five of seven client records reviewed.
Client #1 was admitted on July 16, 2024 and was active at the time of the inspection. Ten release of information forms signed by the client on January 30, 2025, did not specify the specific information to be disclosed.
Client #2 was admitted on October 4, 2024 and was active at the time of the inspection. Ten release of information forms signed by the client on January 30, 2025, did not specify the specific information to be disclosed.
Client #3 was admitted on January 28, 2025 and discharged on May 12, 2025. Nine release of information forms signed by the client on January 30, 2025, did not specify the specific information to be disclosed.
Client #4 was admitted on July 25, 2024 and discharged on September 4, 2024. Six release of information forms signed by the client on July 25, 2024, did not specify the specific information to be disclosed.
Client #5 was admitted on October 8, 2024 and discharged on December 2, 2024. Four release of information forms signed by the client on October 8, 2024, did not specify the specific information to be disclosed.
This is a repeat citation from the May 30, 2024 and May 18, 2023 annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All consent forms will be fully and correctly completed, including the specific information to be released.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 6/6/2025. 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 6/6/2025.
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 adocumented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
On August 29, 2024, resident returned to the facility informing staff that he was hit with a stick in the head on his way to NA. The resident required medical attention, 911 was called and he was transported by EMS to the emergency room. A written unusual incident report was not filed with the Department.
On October 17, 2024, a resident complained to staff of leg pain with leakage. Staff were instructed to call 911, the resident was transported by EMS to emergency room. A written unusual incident report was not filed with the Department.
On November 6, 2024, a resident complained to staff of severe back and leg pain and requested to go to the ER. 911 was called and the resident was transported to the emergency room by EMS. A written unusual incident report was not filed with the Department.
On December 24, 2024, a resident complained to staff of severe stomach pain and throwing up. 911 was called and the resident was transported to the emergency room by EMS. A written unusual incident report was not filed with the Department.
On December 27, 2024, resident complained to staff of severe stomach pain and requested to go to the ER. Resident was transported to the emergency room by EMS. A written unusual incident report was not filed with the Department.
On April 9, 2025 A resident fell to the ground while carrying in food to the facility. His fall was due to a seizure, and he suffered a laceration under his eye that required medical attention. The resident was transported to the emergency room by EMS. A written unusual incident report was not filed with the Department.
This is a repeat citation from the May 30, 2024 annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Supervisor met with Gaudenzia Focus House staff to review incident report policies and procedures on 6/11/2025.
Program Supervisor informed staff that all incidents must be communicated to her.
Program Supervisor will submit all critical incident reports to DDAP via the online portal within 24 hours as per 709.34 (c) (4).
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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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 corrections that were approved by the Department.
A plan of correction for employees receiving a minimum of four hours of TB/STD training was submitted and approved by the Department for the May 30, 2024, and May 18, 2023, annual licensing inspections. Employees receiving a minimum of four hours of TB/STD training was again found to be a deficiency in the May 22, 2025 licensing inspection.
A plan of correction for obtaining client signed consent that included the specific information to be disclosed was submitted and approved by the Department for the May 30, 2024, and May 18, 2023, annual licensing inspections. Obtaining client signed consent that included the specific information to be disclosed was again found to be a deficiency in the May 22, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area above.
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 on implementation of each action item. Any barriers noted will be addressed as appropriate.
The Division Director will report at least monthly to the Deputy 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.
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