INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2026 through May 21, 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present the completed plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit.
At the time of the inspection, the facility was unable to present a completes Staffing Requirements Facility Summary Report, which holds the completed and accurate documentation of staff qualifications and trainings. The facility was presented with the staffing report beginning March 3, 2026 and was notified of the need for corrections multiple times leading up to the day of the inspection. Additionally, the Department licensing representative provided facility staff with several attempts of technical assistance to help make the corrections; however, the staffing report was still not accurate upon final submission.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Staffing Requirements Facility Summary Report shall be completed accurately and on time by the Program Director for each licensing visit.If the Program Director has any questions or difficulty completing the report, they will reach out to their Division Director, Regional Executive Director or Gaudenzia's compliance department.
The Division Director will review the Staffing Report prior to submission to ensure it is completed accurately and completely.
If the report is returned as being incomplete, the Program Director, Division Director and Compliance Department will meet to review and update the report prior to resubmission.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure written individual training plans were developed annually for each employee, which is to include input from both the employee and the supervisor, in one of nine applicable personnel records reviewed.
Employee #4 was hired as a counselor on September 15, 2025. There was no individual training plan for the current training year documented in the personnel record 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
The Training Plan for employee #4 was reviewed with their supervisor, signed and dated on 5/22/26.
The Individual Training Plan (ITP) will be developed upon hire and annually with input from both the employee and the supervisor, as specified in Gaudenzia Policy.
The Individual Training Plan will be finalized, signed by both employee and supervisor within the month of January of each calendar year.
The Regional Clinical Director will review all Training Plans by January 15th of each year to ensure compliance. Any Training Plans not completed will be brought to the Program Directors attention. Once completed, the Program Director will inform the Regional Clinical Director.
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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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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in two of four applicable personnel records reviewed.
Employee #14 was hired as a recovery specialist on June 12, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than June 12, 2025. There was documentation of the timely completion of the TB/STD training; however, there was no documentation indicating the HIV/AIDS training was completed as of the date of the inspection.
Employee #15 was hired as an assessor on March 27, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than March 27, 2025. There was documentation of the timely completion of the TB/STD training; however, there was no documentation indicating the HIV/AIDS training was completed 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.
Employee #14 and #15 will complete the mandatory HIV/AIDS training no later than 7/30/26.
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 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.
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 Regional Executive Director to assist in advocating with the training provider.
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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
At the time of the inspection, which was conducted on May 21, 2026, there was a slip-resistant mat with what appeared to be mold or mildew located in the women's shower in the bathroom adjacent to the TV lounge of the inpatient area of the facility.
This is a repeat citation from the May 15, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The mat identified during the physical plant inspection was removed on 5/22/26 and replaced that same day.
This issue will be monitored during regular health and safety checks. Any missing or unsanitary shower mats will be replaced immediately.
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 Regional Executive Director to address directly with the Maintenance department head.
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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, which was conducted on May 21, 2026, there were two portable space heaters located in room #156 of the assessment and outpatient area of the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The space heaters were immediately removed from the program on 5/22/26.
An all staff meeting will be held by 6/19, 2026 to review the regulation and Gaudenzia Policy and Procedure regarding space heaters not being used in the facility unless they are permanently affixed to a wall to ensure the safety of all clients and staff.
This issue will be monitored during regular health and safety checks. Any spaced heaters found will be immediately removed and the staff member responsible will be reminded of the regulation and policy of no space heaters in the building unless they are permanently affixed to the wall
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 Regional Executive Director to address directly with the Maintenance department head.
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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's May 2025 through April 2026 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the date, time, the amount of time it took for evacuation, the exit route used, the number of people in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
At the time of the inspection, there was documentation indicating four fire drills conducted during the month of August 2025; however, none of the fire drill logs completed for the drills included documentation of which exit route was used for each drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
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 6/22/26. This training will include a detailed review of the standard and all relevant Gaudenzia policies.
The Program Director will review each fire drill held and documented to ensure all of the necessary components, including the exit route used, are included in the fire drill log. If the exit route or any required component of the file drill is not completed, the Program Director will conduct another fire drill for the month to ensure the fire drill log is completed correctly.
The Division Director will review the fire drill log on a quarterly basis to ensure all documentation is found.
The Gaudenzia Compliance Department will conduct a review of the citation 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 written informed and voluntary consent from the client for the disclosure of information contained in the client record in four of twenty-one client records reviewed.
Client #11 was admitted to the inpatient non-hospital detoxification activity on November 22, 2025 and was discharged on November 27, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #13 was admitted to the inpatient non-hospital detoxification activity on November 26, 2025 and was discharged on December 2, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #17 was admitted to the inpatient non-hospital activity on November 27, 2025 and was discharged on November 28, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #19 was admitted to the inpatient non-hospital activity on December 2, 2025 and was discharged on December 23, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was 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 6/22/26. 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 and reviewed by the Program Director to ensure that it is accurate and comprehensive. This will be completed no later than 6/10/26.
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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709.93(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 maintain a complete client record on an individual, which is to include documentation of case consultation notes, in two of five applicable client records reviewed.
Client #4 was admitted to the outpatient activity on October 30, 2025 and was discharged on March 4, 2026. There were no case consultation notes documented in the record at the time of the inspection.
Client #7 was admitted to the outpatient activity on December 10, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
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 Case Consultation Notes.
All active clients will be reviewed to ensure a Case Consult is completed as required. A case consult for Client #7 was completed on 5/29/26.
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 6/22/26. 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 Division 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)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include documentation of follow-up information, in two of four applicable client records reviewed.
Client #5 was admitted to the outpatient activity on December 12, 2025 and was discharged on April 17, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client #6 was admitted to the outpatient activity on July 12, 2025 and was discharged on October 22, 2025. There was no follow-up information documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All follow-up documentation will be completed 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 6/22/26. 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 Division Director to ensure that it is accurate and comprehensive. This will be completed no later than 6/22/26.
The Division 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 Division 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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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display conspicuously to the general public the project hours of operation.
The project policy and procedure manual stated that "although times may vary, dependent on the client-flexible daily schedule and client needs, the hours during which the project generally provides its primary care treatment services are as follow: Monday - Thursday 9:00am- 8:00pm/ Friday: 9:00 am - 5:00 pm. The call center staff will be available 24/7 for screening and referrals."
At the time of the inspection, which was conducted on May 21, 2026, the posted hours of operation were 24 hours a day, 7 days a week, but these hours are for assessments via the call center. The posted hours of operation do not reference those primary care treatment service hours for the outpatient activity.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The primary care treatment service hours for the outpatient program were posted on 5/22/26.
The Division Director will ensure all hours posted are kept up to date and will be monitored through monthly physical plant inspections.
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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