INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 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 Inc. Outreach 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(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 document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in six of seven applicable personnel records reviewed.
Employee # 2 was hired as the Facility Director on October 30, 2023. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 3 was hired as a counselor on December 23, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 4 was hired as a counselor on January 13, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 5 was hired as a counselor on April 11, 2022. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 6 was hired as a counselor on May 9, 2022. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 7 was hired as a counselor on April 26, 2021. There was no current individual training plan documented in the personnel record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Individual Treatment Plan (ITP) will be developed annually with input from both the employee and the supervisor, as specified in Gaudenzia Policy.
When the supervisor completes each employee's performance evaluation during the month of January, they will begin the process of evaluating the employee's training needs for the coming year.
This will be finalized and signed off on by both the supervisor and employee within 1 year of the signature of the previous plan.
Clinical supervisor will create an excel spreadsheet to track employees' trainings throughout the year to ensure that all trainings are completed and up to date.
Clinical supervisor will meet with all staff to ensure that trainings for this year are completed or in progress to start the completion of trainings by 6/30/2025 and signed off by both staff and supervisor.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers.
At the time of the inspection, conducted at approximately 1:30 PM, there were unsecured client records located in a vacant office in room #116.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor met with all staff during a clinical team meeting held on 5/23/25 to discuss this finding.
All staff were informed that client documentation is to be scanned directly into the file and any paper documentation to be secured in locked filing cabinets prior to uploading into the EHR.
Once documents are uploaded, they can then be placed into the secured box provided by the shredding company awaiting pick up to be destroyed.
To ensure that all documentation is filed and secure, clinical supervisor will check in daily with clinical staff and do a daily walk through of physical plant.
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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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 1 was admitted on January 31, 2025 and was still active at the time of the inspection. There was evidence 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 any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor informed staff that all releases must be completed at time of assessment. During the first individual session post assessment consents to be reviewed and if appropriate consent is not on file, then the counselor will obtain consent. This information was reviewed in a clinical team meeting held on 5/23/25 and is an agenda item for all team meetings moving forward.
Clinical supervisor is conducting monthly chart audits for quantitative and qualitative chart reviews.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be 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 a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made on a consent to release information form in one of seven client records reviewed.
Client # 1 was admitted on January 31, 2025 and was still active at the time of the inspection. There was a blank release of information form, signed by the client on January 31, 2025, which did not include documentation of the name of the person, agency or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The clinical supervisor informed staff that all releases must be completed at time of assessment. During the first individual session post assessment consents to be reviewed and if appropriate consent is not on file, then the counselor will obtain consent. This information was reviewed in a clinical team meeting held on 5/23/25 and is an agenda item for all team meetings moving forward.
Clinical supervisor is conducting monthly chart audits for quantitative and qualitative chart reviews.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time.
All staff will be trained on the proper way of completing a release of information to include the name or agency the information is to be released to, what specific information will be disclosed and the purpose of the disclosure.
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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 a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.
Client # 1 was admitted on January 31, 2025 and was still active at the time of the inspection. There was a blank release of information form, signed by the client on January 31, 2025, which did not included documentation of the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The clinical supervisor informed staff that all releases must be completed at time of assessment. During the first individual session post assessment consents to be reviewed and if appropriate consent is not on file, then the counselor will obtain consent. This information was reviewed in a clinical team meeting held on 5/23/25 and is an agenda item for all team meetings moving forward.
Clinical supervisor is conducting monthly chart audits for quantitative and qualitative chart reviews.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time.
All staff will be trained on the proper way of completing a release of information to include the name or agency the information is to be released to, what specific information will be disclosed and the purpose of the disclosure. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client # 1 was admitted on January 31, 2025 and was still active at the time of the inspection. There was a blank release of information form, signed by the client on January 31, 2025, which did not include documentation of the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The clinical supervisor informed staff that all releases must be completed at time of assessment. During the first individual session post assessment consents to be reviewed and if appropriate consent is not on file, then the counselor will obtain consent. This information was reviewed in a clinical team meeting held on 5/23/25 and is an agenda item for all team meetings moving forward.
The clinical supervisor is conducting monthly chart audits for quantitative and qualitative chart reviews.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time.
All staff will be trained on the proper way of completing a release of information to include the name or agency the information is to be released to, what specific information will be disclosed and the purpose of the disclosure.
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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 the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.
Client # 7 was admitted to the inpatient non-hospital activity on January 27, 2025 and was administratively discharged on March 28, 2025. There was no documentation in the record indicating the client was provided written notification of the facility's decision to involuntarily terminate treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All documentation will be completed correctly and in a timely manner.
The Clinical Supervisor will conduct a training with the clinical team on administrative discharge processes, paperwork, and client notification, specifically mailing a notice of termination of treatment to the client prior to the expected date of discharge by June 20th.
The clinical team will sign off on the training.
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 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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a psychosocial evaluation of the client in four of seven applicable client records reviewed.
The facility policy and procedure manual states that a psychosocial evaluation is to be completed within thirty days of admission.
Client # 1 was admitted on January 31, 2025 and was still active at the time of the inspection. There was no psychosocial evaluation documented in the client record at the time of the inspection.
Client # 2 was admitted on February 20, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed no later than March 22, 2025; however, the evaluation was not completed until April 9, 2025.
Client # 4 was admitted on December 18, 2024 and was discharged on March 31, 2025. The psychosocial evaluation was due to be completed no later than January 17, 2025; however, the evaluation was not completed until January 29, 2025.
Client # 7 was admitted on January 27, 2025 and was discharged on March 28, 2025. There was no psychosocial evaluation documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor met with staff on 5/27/25 during a clinical team meeting and reviewed the process of completing the psychosocial evaluation. Staff are to complete the entire psychosocial evaluation at time of the assessment in its entirety.
During the first individual session post assessment counselors will review the client file to ensure all documentation for assessment has been completed.
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 clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in three of seven client records reviewed.
The facility policy and procedure manual states that the individual treatment and rehabilitation plan is to be completed within thirty days of admission.
Client # 1 was admitted on January 31, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than March 2, 2025; however, the plan was not completed until April 18, 2025.
Client # 3 was admitted on November 21, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than December 21, 2024; however, the plan was not completed until April 9, 2025.
Client # 7 was admitted on January 27, 2025 and was discharged on March 28, 2025. There was no individual treatment and rehabilitation plan documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Treatment plan training took place on site 6/12/2025 and was conducted by an approved Gaudenzia trainer. All clinical staff were present at the training time.
Timely submission of treatment plans was an area that was reviewed during this in person training with staff. While discussing timely submission of treatment plans, Gaudenzia's approved workflow was also reviewed, which indicates that a master treatment plan is to be completed within 30 days of admission.
Clinical supervisor is conducting monthly chart audits for quantitative and qualitative chart reviews.
Clinical supervisor will also review for timeliness at time of approval.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 3 was admitted on November 21, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 9, 2025; however, the plan did not include documentation of the proposed type of support services.
Client # 4 was admitted on December 18, 2024 and was discharged on March 31, 2025. The individual treatment and rehabilitation plan was completed on December 24, 2024; however, the plan did not include documentation of the proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Treatment plan training took place on site 6/12/2025 and was conducted by an approved Gaudenzia trainer. All clinical staff were present at the training time.
Support services was an area that was reviewed during the training. Clinical staff were informed of the importance of support services and provided a detailed description of how they are to be documented on client treatment plans.
Clinical supervisor is conducting monthly chart audits for quantitative and qualitative chart reviews. Clinical supervisor will review plan to ensure support services are listed at time of approval.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure counseling services were being provided to the client according to the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client # 1 was admitted on January 31, 2025 and was still active at the time of the inspection. The individual treatment plan, completed on April 18, 2025, indicated the client was to receive one individual therapy session per week. There was no individual therapy session documented in the client's progress notes or record of service after April 18, 2024.
Client # 4 was admitted on December 18, 2024 and was discharged on March 31, 2025. The individual treatment plan, completed on December 18, 2024, and the treatment plan update completed on February 18, 2024, indicated the client was to receive one individual therapy session per week. There was no individual therapy session documented in the client's progress notes or record of service during the weeks of January 19, 2025 through February 8, 2025 and March 9, 2025 through March 15, 2025.
Client # 5 was admitted on September 26, 2024 and was discharged on March 26, 2025. The individual treatment plan, completed on October 1, 2024, and the treatment plan updates completed on December 2, 2024 and February 10, 2025, indicated the client was to receive one individual therapy session every other week. There was only one individual therapy session documented on the client's record of service and progress notes each for the months of January 2025 and February 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Treatment plan training took place on site 6/12/2025 and was conducted by an approved Gaudenzia trainer. All clinical staff were present at the training time.
Frequency of services was an area that was reviewed. Counselors were instructed on how to document services if a client cancels, reschedules, or no shows for a scheduled appointment. Also reviewed appropriate way to update frequency of services on treatment plans when changes are made.
Clinical supervisor is conducting monthly chart audits for quantitative and qualitative chart reviews. Clinical supervisor will review plan to ensure support services are listed at time of approval.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
Progress in this area will be monitored by clinical supervisor and division director in regular supervision sessions, and any barriers to implementation will be addressed at that time
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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, which is to include documentation of case consultation notes, in two of six applicable client records reviewed.
Client # 2 was admitted on February 20, 2025 and was still active at the time of inspection. There was no case consultation notes documented in the records at the time of the inspection.
Client # 3 was admitted on November 21, 2024 and was still active as the time of the inspection. There was no case consultation notes documented in the records at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All documentation will be completed correctly and in a timely manner. This requirement was reviewed with all appropriate staff members and a documented in-service training will occur by 6/27/25.
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 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 6/27/25. The Clinical Supervisor will complete at least weekly reviews and the
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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of an aftercare plan, in two of four applicable client records reviewed.
Client # 4 was admitted on December 18, 2024 and was discharged on March 31, 2025. There was no documentation of an aftercare plan in the record at the time of the inspection.
Client # 7 was admitted on January 27, 2025 and was discharged on March 28, 2025. There was no documentation of an aftercare plan in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All documentation will be completed correctly and in a timely manner. This requirement was reviewed with all appropriate staff members and a documented in-service training will occur by 6/27/25. 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 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 6/27/25. The Clinical Supervisor 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 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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time
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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 maintain a complete client record, which is to include documentation of a discharge summary, in two of four applicable client records reviewed.
Client # 4 was admitted on December 18, 2024 and was discharged on March 31, 2025. There was no documentation of a discharge summary in the record at the time of the inspection.
Client # 7 was admitted on January 27, 2025 and was discharged on March 28, 2025. There was no documentation of a discharge summary in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All documentation will be completed correctly and in a timely manner. This requirement was reviewed with all appropriate staff members and a documented in-service training will occur by 6/27/25. This training will
occur by 6/27/25. 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 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 6/27/25.
The Clinical Supervisor will complete at least weekly reviews
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 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 an administrative review, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure case consultation notes were documented in the client record was submitted and approved by the Department for the October 1, 2020, June 22, 2021, June 15, 2022, June 23, 2023, and May 16, 2024. Failing to include case consultation notes in the client record was again found to be a deficiency in the May 21, 2025, licensing inspection.
A plan of correction for failing to assure counseling sessions are provided according to the individual treatment and rehabilitation plan was submitted and approved by the Department for the June 23, 2023, and May 16, 2024 annual licensing inspections. Failing to assure that counseling sessions are provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the May 21, 2025, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
To avoid repeated citations management staff will work closely with the QA department with Gaudenzia to review files monthly and make the necessary corrections in a timely manner.
Moving forward, the clinical supervisor will review consents for clients newly admitted on a weekly basis to verify consents are on file and all signed by client.
Counseling staff will complete weekly self-audits, clinical supervisor will complete monthly quantitative and qualitative chart audits; Division Director will review open plans of correction at each review.
Any issues noted will be brought to the immediate attention of the clinician responsible, to be corrected within 48 hours.
This POC will begin immediately.
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