INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 2025 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's June 1, 2024 through May 31, 2025 training year, in one of two applicable personnel records reviewed.
Employee # 5 was hired as a counselor on March 16, 2022. The personnel record documented 19 hours of training completed during the training year reviewed.
This is a repeat citation from the September 19, 2023 and September 19, 2024 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director implement a Training Compliance Tracker. The Program Director will monitor the Training Compliance Tracker monthly to ensure that staff are accruing training hours to meet the 25-hour training requirement. Any staff who does not meet the training requirement by the end of the year will be placed on a Written Compliance plan. The Program Director will develop and implement the Training Tracker by October 31, 2025. |
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, the facility provided a copy of the annual report, but there was no verification provided indicating the annual report was made available to the public.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director consulted with the IT staff to add the Annual Report to GPASS' website as a way to disclose the information to the public. This has been done as of 10/13/25. This information is posted under the "Behavioral Health" tab on GPASS' website. Additionally, the names of officers, directors, and principal shareholders are listed on GPASS' website under "Our Team". |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
At the time of the inspection, the facility provided partial financial statements; however, there was no documentation indicating a financial audit, with the auditor's opinion, was completed for the project's fiscal year ending June 30, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/14/2025, The Program Director secured the Independent Auditor's Report from the Fiscal department for the fiscal year ending 2024. The report was completed by a Certified Public Accountant and included documentation which included the financial audit, along with the auditor's opinion. The Program Director will secure the Financial Audit each at the end of each fiscal year and ensure that it is posted on the GPASS website. The Program Director will ensure that the Annual Financial Report is secured, posted on the GPASS website and available every year for the annual DDAP inspection. The Program Director will monitor the GPASS website to ensure that the annual report is always posted and visible to the public. |
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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 2 was admitted on January 24, 2025 and was still active at the time of the inspection. There was evidence of disclosures to the funding source throughout the client's treatment episode; however, there was no valid consent to release information form signed by the client prior to the disclosures.
This is a repeat citation from the September 19, 2023 and September 19, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has met with the Intake Staff and discussed the importance of ensuring that all voluntary consents to release information are completed during the intake process for new and/or reinstated individuals. All consents to release information will be conducted at the time of admission or readmission. The release of information for Client #2 was completed on 10/2/25. The Program Director will conduct chart audits weekly to ensure that all releases of information are complete. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.
Client # 1 was admitted on April 22, 2025 and was still active at the time of the inspection. A release of information form to a probation officer was signed by the client on April 22, 2025; however, the form did not include documentation of the person, agency, or organization to whom the disclosure would be made.
This is a repeat citation from September 19, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has met with the Intake Staff and discussed the importance of ensuring that all disclosures for releases of information are to be completed in its entirety. All releases of information forms will have all information completed to include the name of person, agency, or organization that the disclosure is to be made at the time of admission. The release of information for Client #1 was updated on 10/13/25 to include his parole officer's name and phone number. The Program Director will conduct chart audits weekly to ensure that all releases of information are completed at the time of intake. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on a consent to release information form in one of seven client records reviewed.
Client # 3 was admitted on February 21, 2025 and was still active at the time of the inspection. The release of information form to a health care provider was signed by the client on February 21, 2025; however, the release form did not include documentation of a date, event, or condition upon which the consent would expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with the Intake Staff to discuss the importance of ensuring documentation of the expiration date, event, or condition is checked off on all consents to release information. At the time of admission, the releases of information will be completed to include the date of expiration. The release of information for client #3 was updated in his chart on 10/17/25 which included checking off the expiration date. The Program Director will conduct weekly chart audits to ensure that all releases of information are completed in its entirety at the time of intake. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 ensure individual treatment and rehabilitation plans, developed with the client, were completed within timeframes prescribed in the facility policy in two of five applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 30 days of admission.
Client # 3 was admitted on February 21, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by March 21, 2025; however, the plan was not completed until March 25, 2025.
Client # 4 was admitted on February 21, 2025 and was discharged on July 25, 2025. The individual treatment and rehabilitation plan was due to be completed by March 21, 2025; however, the plan was not completed until March 25, 2025.
Client # 7 was admitted on January 15, 2025 and was discharged on April 30, 2025. The individual treatment and rehabilitation plan was due to be completed by February 15, 2025; however, the plan was not completed until March 11, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the staff meeting held on 10/10/25, the Program Director discussed with the clinical staff the importance of completing treatment plans in a timely manner. The Program Director has developed a tracking system for due dates of documents including Treatment Plans that alerts the staff to complete prior to the due dates of documents. The Program Director will complete weekly chart audits to ensure the compliance of treatment plans. |
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, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on May 19, 2025, indicated the client was to receive one individual session and one group session per week. The record of services and progress notes documented the client only received two individual sessions and two group sessions in June 2025, three individual sessions and two group sessions in July 2025, and one individual session and zero group sessions in August 2025.
Client # 2 was admitted on January 24, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on February 20, 2025, indicated the client was to receive one individual session and one group session per week. The record of services and progress notes documented the client only received one individual session and two group sessions in March 2025, two individual sessions and two group sessions in April 2025, three individual sessions and one group session in May 2025, two individual sessions and one group session in June 2025, zero individual sessions and two group sessions in July 2025 and zero individual sessions and two group sessions in August 2025.
Client # 3 was admitted on February 21, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on March 25, 2025, indicated the client was to receive one individual session and one group session per week. The record of services and progress notes documented the client had received no individual sessions from April 2025 through the date of the inspection. Additionally, the client only received two group sessions in April 2025, two group sessions in May 2025, one group session in June 2025, one group session in July 2025 and zero group sessions in August 2025.
Client # 4 was admitted on February 21, 2025 and was discharged on July 25, 2025. The individual treatment and rehabilitation plan, completed on March 25, 2025, indicated the client was to receive one individual session and one group session per week. The record of services and progress notes documented the client only received two individual sessions in April 2025, two individual sessions in May 2025 and three individual sessions in June 2025.
Client # 5 was admitted on March 27, 2025 and was discharged on June 30, 2025. The individual treatment and rehabilitation plan, completed on April 25, 2025, indicated the client was to receive one individual session and one group session per week. The record of services and progress notes documented the client has received no group sessions from May 2025 through discharge.
Client # 6 was admitted on January 25, 2025 and was discharged on April 29, 2025. The individual treatment and rehabilitation plan, completed on January 30, 2025, indicated the client was to receive one individual session and one group session per week. The record of services and progress notes documented the client only received one individual session and three group session in February 2025 and three individual sessions and three group sessions in March 2025.
Client # 7 was admitted on January 15, 2025 and was discharged on April 30, 2025. The individual treatment and rehabilitation plan, completed on March 11, 2025, indicated the client was to receive one individual session and one group session per week. The record of services and progress notes documented the client received one individual session in April 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/10/25, during the staff meeting, the Program Director discussed the importance of assuring that counseling services are being provided according to the individual's treatment and rehabilitation plan. Staff will document all scheduled appointments in the EHR. When an individual misses a scheduled appointment, the staff will complete a non-billable note to demonstrate that attempts were made to provide counseling services and to identify gaps between planned and delivered services. The Program Director will monitor charts weekly to ensure that services in the treatment plan are provided. |
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, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable client records reviewed.
Client # 4 was admitted on February 21, 2025 and was discharged on July 25, 2025. There was no documentation of follow-up information in the record as of the date of the inspection.
Client # 6 was admitted on January 25, 2025 and was discharged on April 29, 2025. There was no documentation of follow-up information in the record as of the date of the inspection.
This is a repeat citation from the October 13, 2022, September 19, 2023 and September 19, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of October 13, 2025, the Program Director has worked with the EHR to incorporate 60 day and 1 year follow ups to the follow-up call form. The Program Director will establish a follow up tracking log each month for 30, 60, 90, and 1 year follow up calls by running a EHR report. All follow up calls will be made by the Program Director. |
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 informed and voluntary consent forms prior to disclosures of information were submitted and approved by the Department for the September 19, 2023 and September 19, 2024 annual licensing renewal inspections. Failing to complete informed and voluntary consent forms prior to disclosures of information was again found to be a deficiency in the September 23, 2025 annual licensing inspection.
Plans of correction for not documenting follow-up information in the client record were submitted and approved by the Department for the October 13, 2022, September 19, 2023, and September 19, 2024 annual licensing renewal inspections. Failing to document follow-up information in the client record was again found to be a deficiency in the September 23, 2025 annual licensing inspection.
Plans of correction for not ensuring each counselor completed at least 25 clock hours of annual training were submitted and approved by the Department for the September 19, 2023 and September 19, 2024 annual licensing renewal inspections. Failing to ensure counselors completed at least 25 clock hours of annual training document follow-up information in the client record was again found to be a deficiency in the September 23, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Compliance Committee which includes the Medical Director, Program Director, and Lead Counselor will be established. The Compliance Committe will meet on a quarterly basis to review ongoing compliance and verify that all prior POCs remain active. This will be ongoing, and the first meeting is scheduled for November 1, 2025. |