INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection conducted on July 28, 2025 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of administrative information, the facility failed to develop a comprehensive staff development program including an overall plan for addressing needs and an annual evaluation of the overall training plan.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 16, 2025 annual licensure inspection.
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Plan of Correction
1. Prior to the start of a training year (September 1 annually), all employees of the drug and alcohol program will complete a training needs assessment survey identifying individual training needs for the upcoming training year. This assessment survey is to be submitted to the Facility Director no later than August 30th annually.
2. The Facility Director and the Project Director will provide the Staff Development Training Director a list of the identified training subjects by August 31, annually. These subject trainings will be provided by the on-site GJR in PA Trainers and/or the Relias Platform utilized by GJR in PA with completion of the trainings scheduled to occur by August 31 annually.
3. An annual evaluation of the overall training plan from the immediately completed training year is to be completed by the Project Director by 8/31 annually. This evaluation narrative will include the extent to which the training plan met the identified needs and, if needed, how to address any need not met.
4. This updated policy will be submitted to the GJR in PA Administration for approval by August 31, 2025. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information and client records, the facility failed to utilize a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the projects performance in relationship to its stated goals and objectives.
According to the facility's plan of correction from the January 16, 2025 renewal inspection, the facility is to have all records on the electronic health records as of May 1, 2025. However, the facility is still currently utilizing hybrid paper records, electronic health records, and electronic records on facility staff computers which can be unavailable based on whether or not staff are working at the time of inspection.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 16, 2025 annual licensure inspection.
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Plan of Correction
1. The Project Director, Facility Director, and Compliance & Outcomes Coordinator will meet by 9/8/25 to determine how to move all drug and alcohol records to the electronic health record.
2. The electronic health record will have the drug and alcohol treatment records stored in entirety by 12/31/2025.
3. The Compliance & Outcomes Coordinator will confirm completion of the transfer of data by 12/31/2025. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 ensure the clients received counseling services according to their individual treatment plan in seven of seven applicable records. Each treatment plan indicated group therapy should occur daily.
Client #1 admitted to the inpatient level of care on February 25, 2025 and discharged July 18, 2025. There was no documentation the client received group therapy on July 8, July 9, July 11, July 14, July 15, and July 16, 2025.
Client #2 admitted to the inpatient level of care on February 18, 2025 and discharged July 22, 2025. There was no documentation the client received group therapy on July 8, July 9, July 11, July 14, July 15, and July 16, 2025.
Client #3 admitted to the inpatient level of care on June 11, 2025 and was active at the time of reivew. There was no documentation the client received group therapy on July 8, July 9, July 11, July 14, July 15, and July 16, 2025.
Client #4 admitted to the inpatient level of care on June 24, 2025 and was active at the time of reivew. There was no documentation the client received group therapy on July 8, July 9, July 11, July 14, July 15, and July 16, 2025.
Client #5 admitted to the inpatient level of care on February 6, 2025 and discharged May 29, 2025. There was no documentation the client received group therapy on May 5, May 7, May 9, May 14, and May 16, 2025.
Client #6 admitted to the inpatient level of care on January 13, 2025 and discharged June 9, 2025. There was no documentation the client received group therapy on May 2, May 7, May 14, and May 20, 2025.
Client #7 admitted to the inpatient level of care on November 20, 2024 and discharged June 9, 2025. There was no documentation the client received group therapy on May 7, May 14, and May 26, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 and January 16, 2025 annual licensure inspections.
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Plan of Correction
1. The Facility Director met with the Drug and Alcohol counselor, the Drug and Alcohol Case Manager, and the drug and alcohol direct care staff on 8/7/2025 and reviewed regulation 709.52.
2.The treatment plan prescription of services, specifically as it pertains to group therapy, was updated on 8/7/25. It now indicates group therapy-as scheduled and is provided by the Drug and Alcohol therapist and/or assigned group therapists.
3.The Facility Director will review each active client's record to insure compliance with a notation for each group session held. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to ensure the client record included progress notes in seven of seven applicable records.
According to the facilities policy and procedure manual, progress notes should be completed by the counselor within 48 hours of a sessions completion.
Client #1 was admitted to the inpatient level of care on February 25, 2025 and was discharged July 18, 2025. Client #1 ' s record indicated the client received an individual counseling session on May 27, 2025. However, the progress note was not completed until June 2, 2025. Another individual session took place on May 13, 2025, but the progress note was not completed until May 16, 2025. Additionally, Client #1 ' s record indicated that group sessions took place on July 3 and July 7, 2025, but no progress notes for these sessions were found.
Client #2 was admitted to the inpatient level of care on February 18, 2025 and was discharged July 22, 2025. Client #2 ' s record indicated that a group session took place on July 7, 2025. However, no progress note for this session were found.
Client #3 was admitted to the inpatient level of care on June 11, 2025 and was active at the time of review. Client #3 ' s record indicated an individual session took place on July 18, 2025. However, the progress note was not completed until July 21, 2025. Additionally, Client #3 ' s record indicated that a group session took place on July 7, 2025. However, no progress notes for this session were found.
Client #4 was admitted to the inpatient level of care on June 24, 2025 and was active at the time of review. Client #4 ' s record indicated that group sessions took place on July 3, July 7, July 10, July 17, and July 19, 2025. However, no progress notes for these sessions were found.
Client #5 was admitted to the inpatient level of care on February 6, 2025 and was discharged May 29, 2025. Client #5 ' s record indicated that the client received an individual session on May 28, 2025. However, the progress note was not completed until June 2, 2025. Additionally, Client #5 ' s record indicated that group sessions took place on May 1, May 8, and May 15, 2025. However, no progress notes for these sessions were found.
Client #6 was admitted to the inpatient level of care on January 13, 2025 and was discharged June 9, 2025. Client #6 ' s record indicated a group session took place on May 12, 2025. However, the progress note was not completed until June 24, 2025. Additionally, Client #6 ' s record indicated that a group session took place on May 1, May 5, May 8, and May 9, 2025. However, no progress notes for these sessions were found.
Client #7 was admitted to the inpatient level of care on November 20, 2024 and was discharged June 9, 2025. Client #7 ' s record indicated that group sessions took place on May 1, May 2, May 5, May 8, and May 9, 2025. However, no progress notes for these sessions were found.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 16, 2025 annual licensure inspection.
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Plan of Correction
1. The Facility Director met with the Drug and Alcohol Counselor and the Drug and Alcohol Case Manager on 8/7/2025 to review the timeline expectation for completion of progress notes.
2. Progress notes are to be completed and entered by the therapist into the client's record within 72 hours of completion.
3. This change in policy will be submitted to GJR in PA administration for approval by 8/31/2025.
4. The Facility Director will review active client files weekly during team meetings to insure that sessions notes have been entered within the 72 hour completion window.
5. Any and all missing notes will be completed by the therapist within 48 hours following the weekly review meetings and verified by the Facility 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 a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing treatment according to the treatment plan was submitted and approved by the Department for the January 16, 2025, and January 10, 2024 annual licensing inspections. Providing treatment according to the treatment plan was again found to be a deficiency in the July 28, 2025 licensing follow-up inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Facility Director met with Project Director on 7/28/25 to review preliminary findings/deficiencies.
2.Facility Director met with Drug and Alcohol direct care staff, the counselor, and the case manager on 8/7/25 to review deficiencies specific to the treatment plan and provision of services.
3. Facility Director will meet monthly with the Project Director to review active files for compliance with the treatment plan and provisions of service timeframes.
4. Plans of corrections will be reviewed monthly by the Project Director and Facility Director as part of ongoing project supervision. |