INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 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. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.24 (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 policy to contact a client's emergency contact within twelve hours of leaving against medical advice in two out of two applicable records reviewed.
Client #6 was admitted on January 21, 2025 and discharged against facility advice on March 25, 2025. There is no documentation that the emergency contact was contacted.
Client #7 was admitted on August 1, 2024 and discharged against facility advice on August 27, 2024. There is no documentation that the emergency contact was contacted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Program Director will facilitate a review regarding Gaudenzia's policy and procedures for contacting client's emergency contacts within 12 hours of leaving ASA. This will be conducted at our documented monthly staff meeting and will occur no later than 6/2/25.
The program director and recovery support supervisor will verify that all staff have access to the emergency contacts in EHR and will create a binder with that information which will be updated regularly with any changes, so emergency contacts can be notified within the 12-hr. period.
The Program Director will conduct a monthly review of a sample of charts. Any issues noted will be addressed with the staff member in a documented supervision session and corrected immediately.
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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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two out of seven records reviewed.
Client #3 was admitted on February 25, 2025 and was still active at the time of the inspection. There was documentation in the client record that contact was made with a social service provider on March 19, 2025; however, there is no documentation that the facility obtained an informed and voluntary consent for the social service provider.
Client #6 was admitted on January 21, 2025 and was discharged on March 25, 2025. There was documentation in the client record that contact was made with a social service provider on March 19, 2025; however, there is no documentation that the facility obtained an informed and voluntary consent for the social service provider.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Program Director facilitated a review of regulation 709.28 regarding confidentiality and the need to obtain informed and voluntary consent from clients to disclose information in the client record, with Administrative and clinical staff on 05/02/25.
Program Director will also discuss this with all staff on 05/29/25, during our monthly staff meeting. The Program Director will educate or train any new staff on how to properly complete the consents.
The Program Director will conduct an at least monthly review of a sample of charts. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
Program Director, Administrative Coordinator, and Recovery Support Supervisor will ensure that all active clients have current consents documented. This will be completed no later than 6/2/25.
The Program Director will perform weekly reviews of a sample of charts to ensure that all consents are current. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
These processes will all be implemented no later than 6/2/25.
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709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a medical history within five days of admission in six out of seven records reviewed.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. A medical history was due no later than February 17, 2025; however, it was completed on March 17, 2025.
Client #2 was admitted on February 18, 2025 and was still active at the time of the inspection. A medical history was due no later than February 23, 2025; however, it was completed on March 14, 2025.
Client #3 was admitted on February 25, 2025 and was still active at the time of the inspection. A medical history was due no later than March 2, 2025; however, it was completed on March 4, 2025.
Client #4 was admitted on August 19, 2024 and was discharged on March 21, 2025. A medical history was due no later than August 24, 2024; however, it was completed on November 13, 2024.
Client #5 was admitted on February 10, 2025 and discharged on March 18, 2025. A medical history was due no later than February 15, 2025; however, it was completed on March 20, 2025.
Client #7 was admitted on August 1, 2024 and discharged on August 27, 2024. A medical history was due no later than August 6, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical positions have been filled as of 04/28/25, which will help produce better clinical outcomes and care.
All clinical staff have received a current copy of our 3.1 level workflow which is maintained to ensure regulatory compliance with all clinical documentation.
The program director will perform several weekly reviews through our electronic health record system (EHR) to ensure the timeliness of clinical documentation. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a drug and alcohol history within five days of admission in six out of seven records reviewed.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. A drug and alcohol history was due no later than February 17, 2025; however, it was completed on March 17, 2025.
Client #2 was admitted on February 18, 2025 and was still active at the time of the inspection. A drug and alcohol history was due no later than February 23, 2025; however, it was completed on March 14, 2025.
Client #3 was admitted on February 25, 2025 and was still active at the time of the inspection. A drug and alcohol history was due no later than March 2, 2025; however, it was completed on March 4, 2025.
Client #4 was admitted on August 19, 2024 and was discharged on March 21, 2025. A drug and alcohol history was due no later than August 24, 2024; however, it was completed on November 13, 2024.
Client #5 was admitted on February 10, 2025 and discharged on March 18, 2025. A drug and alcohol history was due no later than February 15, 2025; however, it was completed on March 20, 2025.
Client #7 was admitted on August 1, 2024 and discharged on August 27, 2024. A drug and alcohol history was due no later than August 6, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical positions have been filled as of 04/28/25.
All clinical staff have received a current copy of our 3.1 level workflow which is maintained to ensure regulatory compliance with all clinical documentation.
Reinstitution of weekly clinical meetings began once the clinical positions were filled on 04/28/25 which will assist in ensuring documentation completion.
Each Clinician and the Program Director will receive a new whiteboard to be used to track documentation due dates and ensure documentation is current.
The Program Director will perform weekly reviews of a sample of charts to ensure the timeliness of clinical documentation. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
These processes will all implemented no later than 6/2/25.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a personal history within five days of admission in six out of seven records reviewed.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. A personal history was due no later than February 17, 2025; however, it was completed on March 17, 2025.
Client #2 was admitted on February 18, 2025 and was still active at the time of the inspection. A personal history was due no later than February 23, 2025; however, it was completed on March 14, 2025.
Client #3 was admitted on February 25, 2025 and was still active at the time of the inspection. A personal history was due no later than March 2, 2025; however, it was completed on March 4, 2025.
Client #4 was admitted on August 19, 2024 and was discharged on March 21, 2025. A personal history was due no later than August 24, 2024; however, it was completed on November 13, 2024.
Client #5 was admitted on February 10, 2025 and discharged on March 18, 2025. A personal history was due no later than February 15, 2025; however, it was completed on March 20, 2025.
Client #7 was admitted on August 1, 2024 and discharged on August 27, 2024. A personal history was due no later than August 6, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical positions have been filled as of 04/28/25.
All clinical staff have received a current copy of our 3.1 level workflow which is maintained to ensure regulatory compliance with all clinical documentation.
Reinstitution of weekly clinical meetings began once the clinical positions were filled on 04/28/25 which will assist in ensuring documentation completion.
Each Clinician and the Program Director will receive a new whiteboard to be used to track documentation due dates and ensure documentation is current.
The Program Director will perform weekly reviews of a sample of charts to ensure the timeliness of clinical documentation. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
These processes will all implemented no later than 6/2/25.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to complete a physical examination within the facility ' s policy and procedure in three out of seven records reviewed. The facility ' s policy and procedure manual states that the history and physical is due within seven days of admission if the client has not had one within the past six months.
Client #1 was admitted on February 12, 2024 and is still active at the time of the inspection. A physical examination was due no later than February 19, 2025; however, there is no documentation that was one completed.
Client # 4 was admitted on August 19, 2024 and discharged on March 21, 2025. A physical examination was due no later than August 26, 2024; however, there is no documentation that one was completed.
Client # 7 was admitted on August 1, 2024 and discharged on August 27, 2024. A physical examination was due no later than August 8, 2024; however, there is no documentation that one was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All clinical positions have been filled as of 04/28/25, which will help produce better clinical outcomes and care.
The program director will increase attention to referral documents prior to admission and or plan for medical / psychological needs to be conducted within the regulatory timeframes prior to admission.
The administrative coordinator will be taught which items are needed for regulatory compliance and will pre-screen each candidate's referral packet, prior to telephone interview.
The Program Director will conduct a monthly review of a sample of charts. Any issues noted will be addressed with the staff member in a documented supervision session and corrected as soon as possible.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to follow their intake procedures to document a complete psychosocial evaluation within five days of admission in six out of seven records reviewed.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than February 17, 2025; however, it was completed on March 17, 2025.
Client #2 was admitted on February 18, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than February 23, 2025; however, it was completed on March 14, 2025.
Client #3 was admitted on February 25, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than March 2, 2025; however, it was completed on March 4, 2025.
Client #4 was admitted on August 19, 2024 and was discharged on March 21, 2025. A psychosocial evaluation was due no later than August 24, 2024; however, it was completed on November 13, 2024.
Client #5 was admitted on February 10, 2025 and discharged on March 18, 2025. A psychosocial evaluation was due no later than February 15, 2025; however, it was completed on March 20, 2025.
Client #7 was admitted on August 1, 2024 and discharged on August 27, 2024. A psychosocial evaluation was due no later than August 6, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical positions have been filled as of 04/28/25.
All clinical staff have received a current copy of our 3.1 level workflow which is maintained to ensure regulatory compliance with all clinical documentation.
Reinstitution of weekly clinical meetings began once the clinical positions were filled on 04/28/25 which will assist in ensuring documentation completion.
Each Clinician and the Program Director will receive a new whiteboard to be used to track documentation due dates and ensure documentation is current.
The Program Director will perform weekly reviews of a sample of charts to ensure the timeliness of clinical documentation. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
These processes will all implemented no later than 6/2/25.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 complete an individual treatment and rehabilitation plan within the facility ' s policy and procedure manual time line in five out of seven client records reviewed. The facility ' s policy and procedures manual states that an individual treatment and rehabilitation plan is due within seven days of admission.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than February 19, 2025; however, it was completed on March 19, 2025.
Client #4 was admitted on August 19, 2024 and was discharged on March 21, 2025. An individual treatment and rehabilitation plan was due no later than August 26, 2024; however, it was completed on November 13, 2024.
Client #5 was admitted on February 10, 2025 and discharged on March 18, 2025. An individual treatment and rehabilitation plan was due no later than February 17, 2025; however, it was completed on March 17, 2025.
Client #6 was admitted on January 21, 2025 an discharged on March 25, 2025. An individual treatment and rehabilitation plan was due no later than January 28, 2025; however, it was completed on February 28, 2025.
Client #7 was admitted on August 1, 2024 and discharged on August 27, 2024. An individual treatment and rehabilitation plan was due no later than August 8, 2024; however, there is no documentation that one was completed.
This is a repeat citation from the April 17, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All clinical positions have been filled as of 04/28/25.
All clinical staff have received a current copy of our 3.1 level workflow which is maintained to ensure regulatory compliance with all clinical documentation.
Reinstitution of weekly clinical meetings began once the clinical positions were filled on 04/28/25 which will assist in ensuring documentation completion.
Each Clinician and the Program Director will receive a new whiteboard to be used to track documentation due dates and ensure documentation is current.
The Program Director will perform weekly reviews of a sample of charts to ensure the timeliness of clinical documentation. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
These processes will all implemented no later than 6/2/25.
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709.52(a)(3) LICENSURE Support service type
709.52. 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 service on individual treatment and rehabilitation plans in two out of six applicable records reviewed.
Client #2 was admitted on February 18, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan dated March 17, 2025 did not have documented supportive services.
Client #3 was admitted on February 25, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan dated March 12, 2025 did not have documented supportive services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical positions have been filled as of 04/28/25, which will help produce better clinical outcomes and care.
All clinical staff have received a current copy of our 3.1 level workflow which is maintained to ensure regulatory compliance with all clinical documentation.
Reinstitution of weekly clinical meetings began once the clinical positions, were filled, 04/28/25 which will also assist in strategic clinical planning and further development of services to each individual client as well as ensure documentation completion.
Proper education and procedural practices will evolve as individualized training of clinicians, will also occur in this forum.
Each Clinician and Program Director have been purchased a white board, to further assist in visual notification of services due per each client. Boards will be updated by clinician and Program Director.
External support services were added to client #2's treatment plan. Client #2 is still in the program.
External support services for client #3 remain blank as she was remanded into custody on 04/24/25 by her probation officer.
All other existing clients under that specific counselor's caseload will be reviewed by the program director and counselor. If changes are needed, the counselor will make all the necessary changes, and the program director will review, to ensure appropriate documentation is complete.
The Program Director will perform several weekly reviews through our electronic health record system (EHR) to ensure the timeliness of clinical documentation. Any issues noted will be addressed with the staff member in a documented supervision session and corrected within 48 hours.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 ensure that the clients received counseling services according to their individual treatment and rehabilitation plan in four out of six applicable records reviewed.
Client #2 was admitted on February 18, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan dated March 17, 2025 indicated one individual session a week. There was no documentation of the client receiving individual therapy the week of March 31, 2025.
Client #4 was admitted on August 19, 2024 and discharged on March 21, 2025. The individual treatment and rehabilitation plans dated November 13, December 11, 2024, January 10, February 9 and March 7, 2025 indicated weekly individual sessions. There was no documentation that the client received individual sessions the weeks of December 1, 23, 30, 2024, January 6, 13, 20, 27, February 3, 10 and March 3, 2025.
Client #5 was admitted on February 10, 2025 and discharged on March 18, 2025. The individual treatment and rehabilitation plan dated February 11, 2025, indicated one individual session a week. There was no documentation that the client received individual therapy the weeks of February 24 and March 3, 2025.
Client #6 was admitted on January 21, 2025 and was discharged on March 25, 2025. The individual treatment and rehabilitation plan dated January 22, 2025, indicated one individual session a week. There was no documentation that the client received individual sessions the weeks of February 10 and 17, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical vacancies have been filled as of 04/28/25.
As of 05/02/25, the Program Director has provided clinicians with our 3.1 workflow chart, which specifies documentation timeframes in accordance with regulatory compliance and internal policies and procedures. This document is maintained and revised by our CQI and Compliance Departments to ensure adherence.
The Program Director and recovery support supervisor monitor all clinical services provided within the facility to ensure we are meeting weekly clinical hours as well as individual needs; individual sessions, seminars and recovery activities as well as clinical groups.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the facility ' s policy and procedures manual time frame in one out of three applicable client records. The facility's policy and procedures manual states that a case consult occurs every 90 days.
Client #4 was admitted on August 19, 2024 and discharged on March 21, 2025. A case consultation was completed on November 20, 2024, and the next one was due no later than February 20, 2025; however, there is no documentation that one was completed.
This is a repeat citation from the May 5, 2022, May 10, 2023 and April 17, 2024 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical vacancies have been filled as of 04/28/25.
As of 05/02/25, the Program Director has provided clinicians with our 3.1 workflow chart, which specifies documentation timeframes in accordance with regulatory compliance and internal policies and procedures. This document is maintained and revised by our CQI and Compliance Departments.
The Program Director will be completing clinical reviews three times weekly, to illuminate late / absent documents. Clinicians will be notified and will correct documentation within 48 hours.
Weekly clinical meetings have begun as of 05/02/25, in which further discussions on case specific needs or ideas can be discussed at length.
All clinicians and the Program Director will receive their whiteboards to help them remain organized and timely with all clinical documentation.
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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 correction that were approved by the Department.
A plan of correction for completing and documenting case consultations was submitted and approved by the Department for the May 5, 2022, May 10, 2023, and April 17, 2024, annual licensing inspections. Completing and documenting case consultations was again found to be a deficiency in the April 21, 2025.
This is a repeat citation from the April 17, 2024 licensing inspection.
This finding was 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.
This 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 documented supervision sessions to review updates on implementation of each action item.
The Division Director will report at least monthly to the Deputy Director regarding any outstanding items or other areas for improvement.
Any areas noted as not meeting the action items listed 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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