INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, George Junior Republic in Pennsylvania 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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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of applicable client records, the facility failed to document a psychosocial evaluation in three of six records. The facility ' s policy states the psychosocial evaluation must be completed within fourteen days of admission to drug and alcohol program.
Client #3 was admitted on October 16, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due to be completed no later than October 30, 2025; however, this was not completed until November 12, 2025.
Client #4 was admitted on September 9, 2025 and was discharged on October 29, 2025. A psychosocial evaluation was due to be completed no later than September 23, 2025; however, this was not completed until October 3, 2025.
Client #6 was admitted on June 12, 2025 and was discharged on December 12, 2025. A psychosocial evaluation was due to be completed no later than June 26, 2025; however, this was not completed until July 1, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director met with the Therapist and Case Manager on 1/23/26 and provided retraining on the clinical documentation timeframes including the expectation that psychosocial evaluations are to be completed within 14 days of admission to the drug and alcohol program. The Facility Director will provide the Therapist with each new admission's expected psychosocial assessment completion date-within 48 hours of the new admission. The Facility Director will maintain a completion checklist and review it monthly with the Project Director for oversight. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in seven of seven records.
Client #1 was admitted on August 20, 2025 and was still active at the time of the inspection.
A comprehensive treatment and rehabilitation plan was developed with the client on August 22, 2025; however, the treatment plan stated " individual counseling weekly " and " group counseling as scheduled. "
Client #2 was admitted on January 8, 2026 and was still active at the time of the inspection.
A comprehensive treatment and rehabilitation plan was developed with the client on January 9, 2026; however, the treatment plan stated " individual counseling weekly " and " group counseling as scheduled. "
Client #3 was admitted on October 16, 2025 and was still active at the time of the inspection.
A comprehensive treatment and rehabilitation plan was developed with the client on October 22, 2025; however, the treatment plan stated " individual counseling weekly " and " group counseling as scheduled. "
Client #4 was admitted on September 9, 2025 and was discharged on October 29, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on September 12, 2025; however, the treatment plan stated " individual counseling weekly " and " group counseling as scheduled. "
Client #5 was admitted on August 20, 2025 and was discharged on December 16, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on August 21, 2025; however, the treatment plan stated " individual counseling weekly " and " group counseling as scheduled. "
Client #6 was admitted on June 12, 2025 and was discharged on December 12, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on June 13, 2025; however, the treatment plan stated " individual counseling weekly " and " group counseling as scheduled. "
Client #7 was admitted on October 7, 2025 and was discharged on December 30, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on October 10, 2025; however, the treatment plan stated " individual counseling weekly " and " group counseling as scheduled. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with the Therapist and Case Manager on 1/23/26 and provided retraining on the clinical documentation timeframes. The Therapist and Case Manager were instructed that all individual treatment plans must include a prescriptive description and cannot say "as scheduled." The Facility Director will review each monthly plan upon its due date to insure that the proper prescription of services is identified. The Facility Director will maintain a completion checklist and review it monthly with the Project Director for oversight. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in five of six applicable records.
Client #1 was admitted on August 20, 2025 and was still active at the time of the inspection.
A treatment and rehabilitation plan update was completed on November 12, 2025. The next update was due no later than December 12, 2025; however, this was not completed until December 17, 2025.
Client #3 was admitted on October 16, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on November 14, 2025. The next update was due no later than December 14, 2025; however, this was not completed until December 16, 2025.
Client #5 was admitted on August 20, 2025 and was discharged on December 16, 2025. A treatment and rehabilitation plan update was completed on September 15, 2025. The next update was due no later than October 15, 2025; however, this was not completed until October 16, 2025.
Client #6 was admitted on June 12, 2025 and was discharged on December 12, 2025. A treatment and rehabilitation plan update was completed on October 9, 2025. The next update was due no later than November 9, 2025; however, this was not completed until November 12, 2025.
Client #7 was admitted on October 7, 2025 and was discharged on December 30, 2025. A treatment and rehabilitation plan update was completed on November 6, 2025. The next update was due no later than December 6, 2025; however, this was not completed until December 8, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with the Therapist and Case Manager on 1/23/26 and provided retraining on the clinical documentation timeframes including the expectation that individual treatment and rehabilitation plans are to be reviewed with the client at least every 30 days-based on the prior plan's date. The Facility Director provided an updated list to the Therapist and Case Manager for each current client-with dates of completion outlined. The Facility Director will maintain a completion checklist and review it monthly with the Project Director for oversight. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of six applicable records. The facility policy and procedure manual indicate a case consultation to occur within thirty days of admission to the drug and alcohol program, then every sixty days thereafter.
Client #1 was admitted on August 20, 2025 and was still active at the time of the inspection.
The thirty-day case consultation was completed on September 19, 2025. The next sixty-day case consultation was due to occur no later than November 19, 2025; however, this was not completed until November 21, 2025. The next sixty-day case consultation was to occur no later than January 21, 2026; however, this was not completed at the time of the inspection.
Client #3 was admitted on October 16, 2025 and was still active at the time of the inspection. The thirty-day case consultation was completed on November 16, 2025. The next sixty-day case consultation was due to occur no later than January 16, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with the Therapist and Case Manager on 1/23/26 and provided retraining on the clinical documentation timeframes including the expectation that an Initial Case Consultation is completed within 30 days of admission into the drug and alcohol program and then every 60 days after that date. A list of completion dates for the current clients were provided to the Therapist and Case Manager. The Facility Director will provide, within 48 hours of admission, a list of expected completion dates for each new client to the Therapist and Clinical manager. The Facility Director will maintain a completion checklist and review it monthly with the Project Director for oversight. |