This report is a result of an off-site unusual incident investigation conducted on August 21-26, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site investigation, Gaudenzia, Inc. Fountain Springs 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 investigation:
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Plan of Correction
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Observations
Based on a review of information compiled during an investigation into an unusual incident, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving reports of sexual assault by a client.
Two incidents alleging sexual assault by a client were reported to facility staff on July 15, 2026. The facility should have submitted a written unusual incident report with the Department on or before July18, 2026; However, it was submitted on August 24, 2026.
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Plan of Correction
Effective immediately, staff will notify the Program Director or Clinical Supervisor upon learning of any allegation of sexual assault or other reportable unusual incident. The Program Director will ensure the written report is submitted to DDAP within the facility's internal deadline of 24 hours and no later than the required three-business-day timeframe. The Clinical Supervisor will serve as the designated backup when the Program Director is unavailable. Reporting will not be delayed pending completion of an internal investigation or verification of an allegation. The facility will submit additional information as it becomes available.
By October 20, 2026, the Program Director and Clinical Supervisor will review and revise the facility's unusual incident reporting policy and train all staff to identify reportable incidents, notify their supervisor immediately, document requirements, meet reporting deadlines, maintain confidentiality, and follow backup reporting procedures. The facility will maintain training attendance records and staff acknowledgment of the revised policy. These requirements will also be included in new employee orientation.
The Program Director or Clinical Supervisor will maintain an incident tracking log documenting the incident date, the date staff became aware, the reporting deadline, the assigned reporter, the submission date and time, and confirmation of submission. All incidents will be reviewed during daily pulse meetings, with immediate follow-up on any pending report. The facility will maintain submitted reports and submission confirmations in its incident records. Client-related reports will be uploaded to the appropriate electronic health record in accordance with confidentiality requirements.
Beginning in October 2026, the Program Director will conduct weekly audits and monthly audits of all reportable unusual incidents to verify timely submission and supporting documentation. The compliance target is 100%. Any reporting deficiency will result in immediate corrective action, staff retraining as indicated, and weekly monitoring until three consecutive monthly audits demonstrate full compliance.
Responsible parties: Program Director and Clinical Supervisor. Completion date: October 20, 2026, with immediate implementation of reporting safeguards and ongoing monitoring. |