INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 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 Focus House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(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 and administrative documents, the facility failed to develop a written individual training plan with input from both the employee and supervisor in one of four applicable personnel records.
Employee #2 was hired as the facility director on March 24, 2025. The individual training plan was completed by the employee on March 2, 2026. There was no documentation in the personnel file verifying the training plan was completed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Individual Training Plan (ITP) will be developed annually with input from both the employee and the supervisor, as specified in Gaudenzia Policy. Employee#2 and their supervisor reviewed and updated the employees Individual Training Plan on 6/3/26. The Individual Training Plan will be finalized, signed by both employee and supervisor within the month of January of each calendar year. The Program Director will utilize the Relias Training Platform to document each employee's training plan. 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 Director / Supervisor's attention. Once completed, the Program Director will inform the Regional Clinical Director. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
At the time of the inspection, conducted on April 30, 2026 at approximately 9:30am, the thermometer inside the basement walk-in freezer had a reading of 14 degrees Fahrenheit.
This is a repeat citation from the May 22, 2025 and May 30, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All food will be kept at the appropriate temperatures including maintaining the walk-in freezer at or below 0 F.
A new food thermometer has been purchased and placed inside the freezer to ensure an accurate reading.
This issue will be monitored during regular health and safety checks.
The Program Supervisor 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 April 30, 2026 at approximately 9:30 AM, there were three portable space heaters observed. There was one located in the 1st floor case manager's office, one located in the medication room, and one located in the administrative assistant's office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Portable heaters that are not permanently mounted or installed in the facility will not be used in the facility.
The portable heaters found were immediately removed from the facility on the day of the licensing visit.
All staff were reminded to not have or bring portable heaters into the facility on 4/30/2026.
If heaters are needed in the future, the Program Supervisor will discuss the need with the Division Director prior to submitting an order.
If a portable heater is need in the facility, it will be permanently mounted per the regulation.
The Program Supervisor will complete weekly physical plant audits ensuring if portable heaters are used, they are permanently mounted/installed.
The Division Director will complete monthly physical plant audits ensuring if portable heaters are used they are permanently mounted/installed.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client #2 was admitted to the inpatient non-hospital transitional living level of care on May 23, 2025 and was discharged against medical advice (AMA) on October 7, 2025. There was no documentation in the record indicating the emergency contact was notified within twelve hours of the client leaving treatment AMA.
This is a repeat citation from May 22, 2025, May 30, 2024, and May 18, 2023 annual licensing renewal inspections.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Program Supervisor will review with staff during the next staff meeting the requirements for notifying and documenting emergency contacts within 12 hours of a client leaving ASA by 5/22/26.
The Program Supervisor will review all discharge information daily to include whether the Emergency Contact is notified, or attempts were made to notify them within 12 hours of an ASA if a release of information signed by the client has been completed. If the required documentation is not found, the clinician or designee will be required to complete this step immediately.
A Note to Chart will be written for all clients who ASA to include whether there is an appropriate release of information for an emergency contact and if there is, the contact or attempted contacts made with them.
CQI Department will review a sample of discharge charts during semiannual audits.
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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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of corrections that were approved by the Department.
A plan of correction for failing to notify an emergency contact within 12 hours after a client is discharged from the facility against medical advice was submitted and approved by the Department for the May 18, 2023, May 30, 2024, and May 22, 2025 annual licensing inspections. Failing to notify an emergency contact within 12 hours after a client is discharged from the facility against medical advice was again found to be a deficiency in the April 30, 2026 annual licensing inspection.
A plan of correction for failing to keep frozen food at or below 0 degrees Fahrenheit was submitted and approved by the Department for the May 30, 2024 and May 22, 2025 annual licensing inspection. Failing to keep frozen food at or our below 0 degrees Fahrenheit was again found to be a deficiency in the April 30, 2026 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be ultimately responsible for ensuring full implementation of this Plan of Correction as noted in each area of the Plan of Correction.
Implementation will be monitored through at least monthly reviews of the Plan of Correction and documented follow up with any staff member found to be deviating from the action items listed.
The Division Director will meet with the Program Director at least monthly in documented supervision sessions to review and identify barriers to the implementation of each action item. Any barriers noted will be addressed as appropriate.
The Division Director will report at least monthly to the Regional Clinical Director and Regional Executive Director regarding any outstanding items, identified barriers, or other areas requiring improvement.
Any areas noted as not meeting the requirements listed above will be addressed with the Program Director in a documented supervision session note detailing any additional required actions to be taken to bring the program to full compliance.
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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