INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 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. Re-Entry 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, the facility failed to ensure an annual, written individual training plan was developed for each employee, with input from both the employee and the supervisor, in one of six applicable personnel records reviewed.
Employee # 3 was hired as a counselor on December 15, 2024. The individual training plan was developed and signed by the employee on April 23, 2025; however, there was no documentation, in the personnel record, indicating the plan was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and employee # 3 has developed a new individual training plan for 2025-2026. Both have agreed on the plan and have signed and placed in employee's employment file.
PD will develop a Individual Training Plan grid that will be monitored bi-annually to ensure that an individual training plan is developed at the time of the employees' annual performance review.
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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, the facility failed to ensure all staff persons received at least 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 within the regulatory time frame in four of four applicable personnel record reviewed.
Employee # 7 was hired as a residential support staff supervisor on November 26, 2018. The HIV/AIDS and TB/STD trainings were due no later than November 26, 2020; however, there was no documentation indicating that both trainings were completed as of the date of the inspection.
Employee # 8 was hired as a residential support staff on November 7, 2022. The HIV/AIDS and TB/STD trainings were due no later than November 7, 2024; however, there was no documentation indicating that both trainings were completed as of the date of the inspection.
Employee # 9 was hired as a residential support staff on August 15, 2022. The HIV/AIDS and TB/STD trainings were due no later than August 15, 2024; however, there was no documentation indicating that both trainings were completed as of the date of the inspection.
Employee # 10 was hired as a residential support staff on February 12. 2023. The HIV/AIDS and TB/STD trainings were due no later than February 12, 2025; however, there was no documentation indicating that both trainings were completed as of the date of the inspection.
This is a repeat citation from the April 4, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
2 of the Staff members in question was assigned to complete HIV/AIDS (6hrs) and TB/HEP/STI training (4hrs) and completed them on 6/13/25 and it is DDAP approved.
The additional 2 Staff Members was assigned to training which is on 7/18/25 thru Gaudenzia and is DDAP approved.
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 will monitor to ensure full and timely completion.
Certificates of completion will be maintained in the staff file. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and staff schedules, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
The facility provided an April 2025 and May 2025 staff schedule along with staff CPR cards. Several CPR cards provided were effective as of May 2025. There were several shifts in April 2025 that did not have at least one staff member with current CPR certification and first aid training onsite. The facility is a residential facility with their hours of operation being listed as 24 hours per day, 7 days per week.
There were no staff persons with current CPR certification and first aid training working at the facility during the following dates and times: April 3, 2025 from 6:00 PM to 12:00 AM; April 4, 2025 from 5:00 PM to 12:00 AM; April 5, 2025 from 4:00 PM to 12:00 AM; April 6, 2025 from 4:00 PM to 12:00 AM; April 10, 2025 from 6:00 PM to 12:00 AM; April 11, 2025 from 5:00 PM to 12:00 AM; April 12, 2025 from 4:00 PM to 12:00 AM; April 13, 2025 from 4:00 PM to 12:00 AM; April 17, 2025 from 6:00 PM to 12:00 AM; April 18, 2025 from 4:00 PM to 12:00 AM; April 19, 2025 from 8:00 AM to 9:00 AM and 5:00 PM to 12:00 AM; April 20, 2025 from 8:00 AM to 9:00 AM and 5:00 PM to 12:00 AM; April 24, 2025 from 6:00 PM to 12:00 AM; April 25, 2025 from 4:00 PM to 12:00 AM; and April 26, 2025 from 4:00 PM to 12:00 AM.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CPR training have been completed for all current staff and will be valid for the next 2 years.
A training grid is kept and monitored monthly by Re-Entry administrative staff and program director.
This training grid will be monitored on a monthly basis by Gaudenzia administrative staff and ReEntry PD to ensure compliance to DDAP training regulations.
PD and RSP supervisor will review shift schedule on a monthly basis to ensure that at least one staff covering shifts are CPR certified.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon staff employment in one of two applicable personnel records reviewed.
Employee # 2 was hired as the facility director on December 30, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until April 11, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all new employees will have fire safety training during 1st day of unit Orientation.
The Program Director or Recovery Support Professional Supervisor will provide new employees with the Fire Safety tour of facility identifying all extinguishers, fire exits, and AED unit and document in Orientation Supervision and place in employee file.
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 Program Director will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion.
Certificates of completion as well as Evaluations will be maintained in the staff file.
The 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.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.
Employee # 2 was hired as the facility director on December 30, 2024. There was documentation in the personnel record indicating the training to perform assigned tasks during emergencies was not completed until April 11, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director or RSP Supervisor will ensure that all staff will have fire drill training to ensure that they know how to perform the assigned task during an emergency.
Each new employee will have a Fire Drill assigned to their shift so they will be supported by currently trained staff that they can shadow.
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 Program Director will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion.
Certificates of completion as well as Evaluations will be maintained in the staff file.
The 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.
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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 2024 through April 2025 fire drill logs, the facility failed to ensure their written fire drill logs included documentation of the time of the drill, 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 and whether the fire alarm or smoke detector was operative.
The July 26, 2024, September 5, 2024, and September 26, 2024 fire drill logs did not include documentation of the number of persons in the facility at the time of the drill. Additionally, the August 7, 2024 fire drill log did not include documentation that the fire alarm or smoke detector was operative at the time of the drill. Also, the October 31, 2024 fire drill log did not include documentation of the amount of time if took for evacuation, the exit route used, the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative. Finally, the January 22, 2025 fire drill log did not include documentation of the time of the fire drill.
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 ensure that all staff will have fire drill documentation training to include documentation of the number of persons in the facility at the time of the drill; that the fire alarm or smoke detector was operative at the time of the drill; the amount of time if took for evacuation, the exit route used, the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative; and documentation of the time of the fire drill.
The Program Director or RSP supervisor will ensure that will be put on the training grid so it can be monitored monthly.
Program Director and RSP Supervisor will review fire drill logs monthly to ensure that this is being implemented.
If there are any issues noted, they will be brought to the attention of the staff member who completed the report for correction/additional information within 48 hours.
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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 the project's written procedures for the management of treatment/rehabilitation services in one of one applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client # 5 was admitted on October 4, 2024 and was discharged against medical advice on December 6, 2024; however, there was no documentation in the record indicating the emergency contact was notified of the client's discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All clients' Emergency Contact persons will be notified within 12 hours of an ASA discharge of a client.
Program Director created a emergency contact list with members name and their emergency contact name and contact number.
Program Director provided the emergency contact list to the entire Re-Entry House staff and reviewed the policy with staff members on 6/13/25.
The Program 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 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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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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 # 4 was admitted on December 9, 2024 and was administratively discharged on January 21, 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
All clients to be involuntarily discharged will be notified in writing utilizing the form in our EHR specifically designed for this purpose.
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 6/13/25. 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.
The Program 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 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 Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time.
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