INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 2, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greater Philadelphia Alliance Social Service Center 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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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to make available to the public an annual report, which is to include but not be limited to, a statement disclosing the names of officers, directors, and principal shareholders.
At the time of the inspection, a copy of the most recent 2025 annual report was submitted to the Licensing Representative; however, there was no documentation provided indicating the annual report was made available to the public.
This is a repeat citation from the September 23, 2025 annual licensing renewal inspection.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
As of 10/13/26, the Annual Report has been updated on GPASS' website which includes the names of officers, directors, and principal shareholders. This information can be located under the Behavioral Health tab and our Team. The Program Director will monitor and consult with IT and the CEO to ensure that the annual report is updated annually on the website. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in six of six applicable client records reviewed.
Client #1 was admitted on April 22, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 22, 2026 and the first update was due no later than June 22, 2026; however, the update was completed on July 13, 2026.
Client #3 was admitted on March 5, 2026 and was still active at the time of the inspection. A treatment plan update was completed on April 24, 2026 and the next update was due no later than June 24, 2026; however, an update has not been completed.
Client #4 was admitted on November 7, 2025 and was discharged on March 25, 2026. A treatment plan update was completed on December 4, 2025 and the next update was due no later than February 4, 2026; however, the update was not completed prior to discharge.
Client #5 was admitted on December 10, 2025 and was discharged on March 31, 2026. A treatment plan update was completed on January 6, 2026 and the next update was due no later than March 6, 2026; however, the update was not completed prior to discharge.
Client #6 was admitted on January 13, 2026 and was discharged on May 7, 2026. A treatment plan update was completed on March 2, 2026 and the next update was due no later than May 2, 2026; however, the update was not completed prior to discharge.
Client #7 was admitted on November 25, 2025 and was discharged on August 3, 2026. A treatment plan update was completed on December 12, 2025 and the next update was due no later than February 12, 2026; however, the update was completed on April 6, 2026. Additionally, a treatment plan update was due to be completed on June 6, 2026; however, the update was not completed until June 22, 2026.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
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 that counseling services were being provided according to the individual treatment and rehabilitation plan in seven of seven client records reviewed.
Client #1 was admitted on April 22, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on April 22, 2026, indicated the client was to receive one individual session and one group session per week. There was no documentation showing the client received any individual counseling sessions during the weeks of June 14, 2026 through June 28, 2026 and there was no documentation showing the client received any group counseling sessions during the months of May 2026, April 2026, June 2026, July 2026, and during the weeks of August 16, 2026 and August 23, 2026.
Client #2 was admitted on July 8, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on August 7, 2026, indicated the client was to receive three group sessions per week. There was no documentation showing the client received any group counseling sessions during the week of August 16, 2026.
Client #3 was admitted on March 5, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on April 24, 2026 indicated the client was to receive one individual session and one group session per week. There was no documentation showing the client received any group counseling sessions during the weeks of May 3, 2026, May 10, 2026, July 12, 2026, August 2, 2026, August 16, 2026, and August 23, 2026.
Client #4 was admitted on November 7, 2025 and was discharged on March 25, 2026. The individual treatment and rehabilitation plan, completed on December 4, 2025, indicated the client was to receive one individual session and one group session per week. There was no documentation showing the client received any individual counseling session during the weeks of December 21, 2025, January 11, 2026, February 8, 2026, February 22, 2026 and March 1, 2026. Additionally, there was no documentation showing the client received any group counseling session during the weeks of January 4, 2026, January 25, 2026, February 8, 2026, February 22, 2026, March 1, 2026, and March 8, 2026.
Client #5 was admitted on December 10, 2025 and was discharged on March 31, 2026. The individual treatment and rehabilitation plan, completed on January 6, 2026, indicated the client was to receive one counseling session per week. There was no documentation showing the client received any counseling sessions during the weeks of January 18, 2026, February 22, 2026, March 1, 2026, March 8, 2026, and March 22, 2026.
Client #6 was admitted on January 13, 2026 and was discharged on May 7, 2026. The individual treatment and rehabilitation plan, completed on January 13, 2026, indicated the client was to receive one individual counseling session and one group counseling session per week. There was no documentation showing the client received any group counseling sessions during the weeks of February 15, 2026 through March 29, 2026 and April 12, 2026 through April 26, 2026.
Client #7 was admitted on November 25, 2025 and was discharged on August 3, 2026. The individual treatment and rehabilitation plan, completed on December 12, 2025, indicated the client was to receive one individual counseling session and one group session per week. There was no documentation showing the client received any individual counseling sessions during the weeks of December 14, 2025, January 25, 2026, February 15, 2026, March 1, 2026, April 19, 2026, May 10, 2026, May 17, 2026, May 24, 2026, June 21, 2026, and June 28, 2026. Additionally, there was no documentation showing the client received any group counseling sessions during the weeks of December 21, 2025 and December 28, 2025, or for the month of January 2026, February 2026, and March 2026.
This is a repeat citation from the September 23, 2025 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 10/1/26 during the staff meeting, the Program Director discussed that goal objectives are to be realistic and achievable. The counselors and clients will collaborate to develop realistic goals/objectives and refrain from using objectives such as attendance at individual sessions and/or group sessions which may potentially be unrealistic if the client fails to be available for these sessions. Failure to attend any session will be documented in the client's chart. Charts will be audited weekly by Lead Counselor and twice a month by the Program Director. |
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 and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in two of four applicable client records reviewed.
The facility's policy and procedure manual stated case consultations will occur quarterly.
Client #1 was admitted on April 22, 2026 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #6 was admitted on January 13, 2026 and was discharged on May 7, 2026. There were no case consultation notes documented in the record at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
During the staff meeting on 10/1/26, the Program Director informed the staff about the importance of completing documents on time. The Program Director will post alerts each month to notify staff that a document or Case consultation is due. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of three applicable client records reviewed.
The facility's policy and procedure manual stated follow-up information will occur 30 days after discharge, 60 days after discharge, 90 days after discharge, and one year after discharge.
Client #4 was admitted on November 7, 2025 and was discharged on March 25, 2026. There was no 30-day follow-up information documented in the record at the time of the inspection.
Client #5 was admitted on December 10, 2025 and was discharged on March 31, 2026. The 60-day follow-up should have been completed no later than May 31, 2026; however, the follow-up was completed on June 9, 2026.
This is a repeat citation from the October 13, 2022, September 19, 2023, September 19, 2024, and September 23, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director consulted with the EHR to update their system be able to run accurate reports. As of 10/13/26, the report function with the EHR has been updated which allows the Program Director to run a report for follow ups at 30, 60, 90, and 1 yr. |
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.
Plans of correction for not completing follow-up information in the client record were submitted and approved by the Department for the October 13, 2022, September 19, 2023, September 19, 2024, and September 23, 2025 annual licensing renewal inspections. Failing to complete follow-up information in the client record was again found to be a deficiency in the September 2, 2026 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The EHR was updated to ensure that reports ran within its system are accurate without omitting some clients. Follow up calls will be completed by the Clinical Supervisor or Program Director to ensure compliance with documenting treatment plans. |