INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Genesis House - Harrisburg 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)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative documents, the project director failed to follow the facility ' s comprehensive staff development program for agency personnel and complete an overall plan for addressing staff training needs.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Cited finding
The Project Director did not complete an overall plan addressing staff training needs as required by the facility staff development program.
Accountable staff
Project Director, supported by the designated Training Coordinator; Compliance verifies completion.
Plan of correction
Correct the identified deficiency. By November 5, the Training Coordinator will inventory every employee's role, current individual training plan, completed training, outstanding requirements, performance findings, and staff feedback. The Project Director will use this assessment to approve a written overall training plan by November 12.
Change the process. The plan will identify priority topics, intended staff, learning objectives, trainer or course, scheduled completion date, coverage arrangements, and evidence of completion. It will specifically address consent review, treatment plan deadlines, planned service delivery, timely notes, discharge follow-up, fire extinguishers, and emergency duties. Role-specific regulatory training requirements will be checked separately; a course assignment will not count as completion.
Implement and sustain. The Training Coordinator will enter all due dates in a central tracker, reconcile available Relias records with certificates and attendance records, and alert supervisors 30 and 7 days before deadlines. The Project Director will approve the next calendar-year plan by December 31 and revise it when staffing, services, or audit findings change.
Monitoring and prevention of recurrence
The Training Coordinator will review 100% of staff training records monthly for three months, then quarterly. Compliance will verify that every identified need has an assigned action and date, and that all due activities are completed. Any overdue item will be escalated to the Project Director the same business day with a recovery assignment.
Evidence of implementation
Staff needs inventory; dated and signed overall plan; training calendar; certificates and attendance; monthly completion reports.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documents, the project director failed to follow the facility ' s comprehensive staff development program for agency personnel and complete an annual evaluation of the 2025 overall training plan.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Cited finding
The Project Director did not complete the annual evaluation of the 2025 overall training plan.
Accountable staff
Project Director and Training Coordinator; Compliance reviews the evaluation.
Plan of correction
Correct the identified deficiency. By November 12, the Project Director will complete and sign a retrospective evaluation of 2025 training using available plans, attendance, certificates, employee feedback, supervision records, and performance results. Missing source material will be identified as unavailable; the evaluation will be dated when actually completed.
Change the process. The evaluation will compare planned and completed training, assess relevance to staff needs, identify unmet requirements, and examine whether staff applied training through chart audits and observed work. It will document conclusions, corrective actions, owners, and due dates. Where evidence is insufficient, effectiveness will be recorded as undetermined rather than assumed.
Implement and sustain. The Training Coordinator will collect feedback after each training and obtain supervisor observations within 30 days when applicable. A year-end evaluation will be due January 31 after each calendar year, beginning January 31, 2027 for 2026. Preliminary findings will inform the next plan by December 31; the final evaluation will trigger revisions as needed.
Monitoring and prevention of recurrence
Compliance will check the evaluation calendar quarterly and confirm a signed annual evaluation by the scheduled deadline. The Project Director will review evaluation action items monthly until closed. The target is one completed evaluation for every training year, with each improvement assigned and tracked.
Evidence of implementation
Dated 2025 retrospective evaluation; source inventory and limitations; feedback form; annual evaluation calendar; action-item log.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records and staff training records, the project failed to instruct staff in the use of the fire extinguisher upon employment in one out of one applicable record reviewed. Employee #3 was hired as a counselor on August 6, 2026, and was current in that position at the time of the inspection. There was no documentation that this employee was trained in the use of the fire extinguisher upon employment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Cited finding
Employee #3, a counselor hired August 6, 2026, had no documentation of fire extinguisher instruction upon employment.
Accountable staff
Harrisburg site supervisor and designated safety trainer; Training Coordinator maintains records.
Plan of correction
Correct the identified deficiency. By October 30, the supervisor will check Employee #3's file for authentic contemporaneous evidence. If none exists, the employee will receive documented instruction before the next independent onsite assignment. Instruction completed now will carry the actual date; it will not be represented as instruction at hire.
Change the process. Instruction will cover extinguisher locations, appropriate use, limitations, safe access to an exit, alarm activation, evacuation, and demonstration of the operating steps. Staff will be instructed to prioritize evacuation and emergency notification and never delay evacuation to fight a fire. The trainer will document the employee's explanation or demonstration of the procedure.
Implement and sustain. By October 30, the Training Coordinator will review every current Harrisburg staff file and address any other missing instruction before independent onsite work. The new-hire checklist will require this training upon employment on the first workday, before client duties. A supervisor will verify dated employee and trainer acknowledgments before releasing the orientation checklist.
Monitoring and prevention of recurrence
The supervisor will check every new-hire checklist before independent onsite work. Compliance will audit all hires monthly for three months and quarterly thereafter. The target is 100% documented instruction upon employment; a missing record triggers immediate training and a review of why onboarding clearance failed.
Evidence of implementation
Employee #3 training record; current staff audit; revised orientation checklist; competency record; supervisor sign-off.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the review of personnel records and staff training records, the project failed to ensure that personnel on all shifts are trained to perform assigned tasks during emergencies in one out of one applicable record reviewed.Employee #3 was hired as a counselor on August 6, 2026, and was current in that position at the time of the inspection. There was no documentation that this employee was trained to perform assigned tasks during emergencies.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Cited finding
Employee #3 had no documentation of training to perform assigned tasks during emergencies.
Accountable staff
Harrisburg site supervisor and safety trainer; Project Director ensures shift coverage.
Plan of correction
Correct the identified deficiency. By November 12, Employee #3 will receive and demonstrate site-specific emergency duty instruction before independent onsite work. The site supervisor will check all personnel across every operating shift, including part-time and contract staff, and train anyone without verified instruction.
Change the process. A written shift assignment sheet will identify a lead and backup for emergency notification, directing evacuation, assisting people who need help, bringing available attendance information, accounting for clients and staff at the assembly area, and communicating with responders. Assignments will cover both occupied floors, alternate exits, and situations in which the usual lead is absent. Staff will not reenter until authorized.
Implement and sustain. The trainer will conduct a walkthrough and role-based scenario with each affected staff member, document observed understanding, and reteach unsuccessful steps. Emergency duty instruction will be required during initial orientation and before working a new shift or location with different duties. Monthly fire drills will be used to verify that assigned duties work under normal staffing conditions.
Monitoring and prevention of recurrence
The supervisor will reconcile the shift roster with training records before coverage is assigned. Each drill will identify gaps and an owner for correction before the next affected assignment. Compliance will review 100% of staff and shift assignments monthly for three months, then quarterly; target 100% trained coverage.
Evidence of implementation
Employee #3 competency record; all-shift training roster; role and backup assignments; emergency procedure; drill records and corrective actions.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Cited finding
The Project Director did not prepare, annually update, and sign the written project policy and procedure manual.
Accountable staff
Project Director, with Compliance and department leads.
Plan of correction
Correct the identified deficiency. By November 12, the Project Director will review the complete current manual, reconcile conflicting versions, update procedures affected by these findings, and sign and date a review attestation identifying the manual version and the policies reviewed. The review will include unchanged policies rather than only newly revised sections.
Change the process. Compliance will maintain a controlled index with policy title, owner, version, effective date, last review, next review, and approval. The Project Director will approve revisions and confirm that written procedures match actual staffing and workflows. Superseded versions will be archived and removed from routine use.
Implement and sustain. Supervisors will distribute revised policies and obtain staff acknowledgment and practical instruction before staff use the revised process. Urgent interim instructions will take effect immediately while the full review proceeds. The next complete signed review will occur no later than November 12, 2027, with 60-day and 30-day reminders and interim updates when requirements change.
Monitoring and prevention of recurrence
Compliance will review the policy index quarterly and alert the Project Director to missing approvals or upcoming deadlines. The target is a complete, current, signed manual reviewed at least annually and documented staff access to the approved version. Overdue policies will be escalated to the Project Director immediately.
Evidence of implementation
Controlled policy index; signed and dated manual attestation; revision history; archived versions; staff training and acknowledgments.
The annual signing is in May of 2026. We have this documentation to present that it was indeed reviewed and signed but will complete an additional review for November 12, 2026 due to citation and then continue the review May of 2027.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven records reviewed.Client #2 was admitted on March 12, 2026, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.Client #3 was admitted on May 12, 2026, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.Client #4 was admitted on November 16, 2025, and was discharged April 28, 2026. The client ' s funding source became active on December 1, 2025; however, the release of information form for the funding source was not documented in the client record.This is a repeat citation from the October 28, 2025, annual licensing renewal inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Cited finding
Clients #2 and #3 had billing disclosures without a documented funding-source release; Client #4 lacked a release for the funding source active December 1, 2025. This repeats the October 28, 2025 citation.
Accountable staff
Intake and billing leads with treating clinicians; Compliance reviews past disclosures; Project Director, Regional Clinical Director, Facility Director oversees correction.
Plan of correction
Correct the identified deficiency. By October 30, staff will flag affected records and stop further consent-dependent disclosures or claims without a verified valid consent. For Clients #2 and #3, if still active, clinicians will explain and seek voluntary, current-dated consent before further disclosure. For discharged Client #4, staff will preserve the historical record and obtain authorization only if a new disclosure is needed; a new signature will not authorize past disclosures.
Change the process. By November 5, intake will verify the funding source and required consent before initial billing. Billing staff will independently check the actual form for recipient, permitted information, purpose, signatures, expiration, and revocation status before each claim release. A payer change will reopen the consent check. If EM cannot enforce this, a restricted manual clearance log will be required. A general treatment consent or insurance card will not substitute for disclosure authorization.
Review and implement. By November 19, Compliance will review all active Harrisburg funding consents and all discharges since October 28, 2025, including the cited records. For any suspected unauthorized disclosure, Compliance will document what was disclosed, to whom and when, evaluate applicable privacy and notification duties, and track remediation. Staff will explain options when consent is declined without coercion; any lawful exception requires documented Compliance review.
Monitoring and prevention of recurrence
Billing will check 100% of claim releases. Compliance will independently audit all new or changed funding consents weekly for 90 days and a monthly sample of 10 or all if fewer thereafter. Target 100% valid authorization or documented lawful basis. Any defect triggers a disclosure hold, same-day escalation, and expansion to all comparable records.
Evidence of implementation
Revised intake and billing checklist; current consents; claim clearance log; cited-client review; disclosure assessment and remediation log; audit results.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in three of seven records reviewed.Client #1 was admitted on February 4, 2026, and was a current client at the time of the licensing inspection. A release of information form for the emergency contact, signed by the client on February 4, 2026, did not specify the specific information to be disclosed.Client #4 was admitted on November 16, 2025, and was discharged April 28, 2026. A release of information form for the emergency contact, signed by the client on November 17, 2025, did not specify the specific information to be disclosed.Client #7 was admitted on March 18, 2026, and was discharged September 18, 2026. A release of information form for the probation officer, signed by the client on March 18, 2026, did not specify the specific information to be disclosed.This is a repeat citation from the October 28, 2025, annual licensing renewal inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Cited finding
Releases for emergency contacts for Clients #1 and #4 and probation for Client #7 did not identify the specific information to be disclosed. This repeats the October 28, 2025 citation.
Accountable staff
Clinical Supervisor, Regional Clinical Director, Compliance; Compliance approves the form and audits disclosures.
Plan of correction
Correct the identified deficiency. By October 30, staff will flag the deficient releases as unusable for further consent-dependent disclosure. For Client #1, if still active, the clinician will explain the intended information and obtain a newly signed, current-dated release before using it. For discharged Clients #4 and #7, Compliance will document the deficiency and review actual disclosures; no new form will be presented as correcting past authorization.
Change the process. By November 5, the approved release will require an explicit selection or description of the information authorized. Staff will distinguish attendance or participation information from assessments, treatment plans, or other clinical content, and use only legally permitted categories relevant to the recipient and purpose. Blank categories and ambiguous language such as "all information" will not pass review. Staff will not complete blank authorization fields after the client signs.
Implement and sustain. Staff will review the completed information field with the client, offer a copy, and obtain supervisory verification before a release is used. By November 19, the Clinical Supervisor will review all active releases and releases in all Harrisburg discharges since October 28, 2025. Staff will replace defective active forms with informed authorization and route possible past improper disclosures to Compliance.
Monitoring and prevention of recurrence
The supervisor will check every new or revised release before use. Compliance will audit all such releases weekly for 90 days, then 10 monthly or all if fewer. Target 100% specific, completed information fields. A failed form blocks further consent-dependent disclosure and triggers same-day coaching and review of the staff member's other current releases.
Evidence of implementation
Revised release template; client education and copy-offer documentation; replacement consents where appropriate; retrospective audit; pre-use checklist.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in three of seven records reviewed.Client #1 was admitted on February 4, 2026, and was a current client at the time of the licensing inspection. A release of information form for a friend, signed by the client on February 4, 2026, did not specify the purpose of disclosure.Client #4 was admitted on November 16, 2025, and was discharged April 28, 2026. A release of information form for a family member, signed by the client on November 17, 2025, did not specify the purpose of disclosure.Client #7 was admitted on March 18, 2026, and was discharged September 18, 2026. A release of information form for a probation officer, signed by the client on March 18, 2026, did not specify the purpose of disclosure.This is a repeat citation from the October 28, 2025, annual licensing renewal inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Cited finding
Releases for a friend for Client #1, a family member for Client #4, and a probation officer for Client #7 omitted the purpose of disclosure. This repeats the October 28, 2025 citation.
Accountable staff
Clinical Supervisor, Regional Clinical Director, Project Director; Compliance monitors form completeness.
Plan of correction
Correct the identified deficiency. By October 30, staff will flag the cited forms and not rely on them for further consent-dependent disclosure. The clinician will discuss the purpose with Client #1 if still active and obtain a complete current-dated release before disclosure. For discharged Clients #4 and #7, Compliance will preserve the original forms, document the omission, and review whether disclosures occurred.
Change the process. By November 5, the release form will require a clear purpose separate from the recipient and specific information fields. Staff will describe the actual reason, such as coordinating an agreed support role, arranging payment, or reporting authorized attendance to probation. Naming "family," "friend," or "probation" alone will not constitute a purpose. The client will review and voluntarily authorize the completed purpose before signing.
Implement and sustain. Intake and clinical staff will practice completing example forms and demonstrate that the recipient, information, and purpose are distinct. A second reviewer will reject any blank or unclear purpose before use. By November 19, staff will audit active releases and releases in all Harrisburg discharges since October 28, 2025, replacing active deficient forms only with valid current consent and documenting historical findings without backdating.
Monitoring and prevention of recurrence
The supervisor will verify purpose on every new or revised release. Compliance will audit all such forms weekly for 90 days, then 10 monthly or all if fewer. Target 100% clear purposes. A defect prompts a hold on consent-dependent disclosure, same-day staff feedback, and review of related forms; repeat defects go to the Project Director.
Evidence of implementation
Purpose-required release template; training examples and competency results; corrected active releases; audit and disclosure-review logs.
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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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in four out of six applicable records reviewed. Client #1 was admitted on February 4, 2026, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on February 19, 2026, with the first update due no later than April 19, 2026, and the next two updates due no later than June 19, 2026, and August 19, 2026; however, there were no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.Client #3 was admitted on May 12, 2026, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on July 20, 2026, with the first update due no later than September 20, 2026; however, there were no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.Client #4 was admitted on November 16, 2025, and was discharged April 28, 2026. A comprehensive treatment and rehabilitation plan was documented in the record on December 11, 2025, with the first update due no later than February 11, 2026 and the next update due no later than April 11, 2026; however, there were no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.Client #5 was admitted on February 3, 2026, and was discharged July 7, 2026. A comprehensive treatment and rehabilitation plan was documented in the record on February 9, 2026, with the first update due no later than April 9, 2025, and the next update due no later than June 9, 2026; however, there were no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Cited finding
Treatment plan updates were absent for Clients #1, #3, #4, and #5 within the required review intervals.
Accountable staff
Primary clinicians and Harrisburg Clinical Supervisor; Compliance checks deadline calculations.
Plan of correction
Correct the identified deficiency. By October 30, the supervisor will identify every active client with an overdue plan, including Clients #1 and #3 if still active, and arrange prompt clinical review. By November 5, clinicians will complete current reviews using available clinical information and client participation where obtainable, documenting outreach, absence, or refusal. Discharged Clients #4 and #5 will receive a historical deficiency review; staff will not create fictitious past reviews.
Change the process. By November 5, the supervisor will establish a roster with the initial plan date, last completed review, next due date, clinician, and supervisor verification. Due dates will use actual calendar-day arithmetic and never exceed 60 days; "two months" will not substitute. Alerts will be set 14 and 7 days before due dates, with review appointments targeted before day 60 and coverage assigned during staff leave.
Implement and sustain. The supervisor will review the full active roster weekly, escalate missed deadlines immediately, and verify that updates address progress, barriers, goals, interventions, service frequency, and current needs. A late review will use the actual date and remain recorded as late. By November 12, Compliance will verify every active record and the four cited records against the tracker.
Monitoring and prevention of recurrence
The supervisor will review 100% of due plans weekly for 90 days and monthly thereafter, while weekly alerts continue. Target 100% of reviews completed within 60 days. A missed deadline triggers same-day escalation, a prompt current review, and review of the responsible clinician's entire caseload.
Evidence of implementation
Active-client due-date roster; current completed reviews; historical findings; reminder records; weekly supervisor sign-offs. The inspection's apparent date discrepancies are identified in the submission notes.
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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 project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four out of seven records reviewed.Client #1 was admitted on February 4, 2026, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan documented in the client record on February 9, 2026, indicated that the client was to receive one individual counseling and two group counseling sessions per week; however, there were no individual counseling sessions documented in the record for the months of August 2026 and September 2026 and no group counseling sessions documented in the record for the months of July 2026, August 2026 and September 2026.Client #2 was admitted on March 12, 2026, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan documented in the client record on April 1, 2026, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record for the weeks of April 12, 2026 through April 18, 2026, July 12, 2026 through July 18, 2026, and August 30, 2026 through September 5, 2026.Client #3 was admitted on May 12, 2026, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan update documented in the client record on July 20, 2026, indicated that the client was to receive one individual counseling and two group counseling sessions per week; however, there were no individual counseling sessions documented in the record for the months of August 2026 and September 2026.Client #6 was admitted on April 23, 2026, and was discharged on September 17, 2026. A comprehensive treatment and rehabilitation plan documented in the client record on April 29, 2026, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the record for the weeks of May 31, 2026 through June 6, 2026, June 7, 2026 through June 13, 2026, August 9, 2026 through August 15, 2026, and August 23, 2026 through August 29, 2026.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Genesis House, Inc. will ensure that clients receive counseling services at the type and frequency specified in their individual treatment and rehabilitation plans.
Responsible persons: Project Director, Harrisburg Clinical Supervisor, treating clinicians, and scheduling staff.
The Harrisburg Clinical Supervisor will review the service records for Clients #1, #2, #3, and #6 for the periods identified in the inspection. This review will determine whether prescribed counseling was missed or provided without supporting documentation. Missing services will not be recorded as completed. Any documentation added for a verified service will follow late-entry procedures and reflect the actual entry date.
For Clients #1, #2, and #3, if still enrolled, the assigned clinician and scheduling staff will ensure appointments are scheduled and services are offered at the frequency prescribed in their treatment plans. This includes one individual and two group counseling sessions weekly for Clients #1 and #3, and one individual counseling session weekly for Client #2, unless their current approved plans prescribe a different frequency. Client #6's discharged record will be reviewed to identify the service-delivery failures and incorporate those findings into staff supervision and corrective action.
The Clinical Supervisor will implement a weekly service-delivery log for all active clients. The log will identify prescribed counseling frequency, scheduled sessions, completed sessions, missed sessions, and corrective action. Each week, the supervisor will compare actual attendance and service documentation with the counseling requirements in each client's plan.
When Genesis House cancels a session because of staff absence or another operational issue, the supervisor will arrange qualified coverage or rescheduling within the prescribed service interval whenever possible. Any unresolved interruption will be escalated promptly to the Project Director for corrective action.
When a client misses or declines a prescribed session, the assigned clinician will attempt contact by the next business day, offer rescheduling, address barriers to attendance, and document the outcome. Repeated missed sessions will prompt supervisory review and an individualized engagement response. Outreach and scheduling attempts will not be counted as counseling services delivered.
All clinical and scheduling staff will receive instruction on matching appointments and delivered services to the prescribed counseling frequency. The Clinical Supervisor will review all active client records weekly for 90 days, with monthly oversight by the Project Director. Monitoring will measure completed sessions against prescribed sessions and confirm that every service gap receives documented follow-up. Monthly audits will continue after sustained compliance; recurring deficiencies will result in continued weekly monitoring and additional staff corrective action. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within 24-hours of the date of service, per facility policy, in five out of seven records reviewed.Client #1 was admitted on February 4, 2026, and was a current client at the time of the licensing inspection. The record contained individual progress notes for sessions occurring on February 4, 2026 and February 10, 2026, that were not documented until February 16, 2026; sessions occurring on February 17, 2026 and February 25, 2026, that were not documented until March 2, 2026; a session occurring on March 3, 2026, that was not documented until March 9, 2026; a session occurring on April 7, 2026, that was not documented until April 13, 2026; sessions occurring on April 28, 2026 and May 12, 2026, that were not documented until May 24, 2026; sessions occurring on June 16, 2026 and June 23, 2026, that were not documented until July 9, 2026; and a session occurring on July 14, 2026, that was not documented until July 21, 2026.Client #2 was admitted on March 12, 2026, and was a current client at the time of the licensing inspection. The record contained individual progress notes for sessions occurring on April 9, 2026, and April 14, 2026, that were not documented until April 27, 2026; a session occurring on May 5, 2026, that was not documented until May 21, 2026; sessions occurring on June 16, 2026, June 17, 2026, June 24, 2026, and June 30, 2026, that were not documented until July 15, 2026; and sessions occurring on July 6, 2026, and July 7, 2026, that were not documented until July 20, 2026.Client #3 was admitted on May 12, 2026, and was a current client at the time of the licensing inspection. The record contained individual progress notes for sessions occurring on June 16, 2026, and June 29, 2026, that were not documented until July 9, 2026; and a session occurring on July 13, 2026, that was not documented until July 21, 2026. Client #4 was admitted on November 16, 2025, and was discharged April 28, 2026. The record contained individual progress notes for a session occurring on November 25, 2025, that was not documented until December 2, 2025; sessions occurring on January 21, 2026 and February 3, 2026, that were not documented until February 12, 2026; a session occurring on February 17, 2026, that was not documented until March 2, 2026; a session occurring on March 17, 2026, that was not documented until March 26, 2026; a session occurring on April 7, 2026, that was not documented until April 14, 2026; and a session occurring on April 14, 2026, that was not documented until April 28, 2026.Client #6 was admitted on April 23, 2026, and was discharged on September 17, 2026. The record contained individual progress notes for a session occurring on April 29, 2026, that was not documented until May 6, 2026; a session occurring on May 12, 2026, that was not documented until May 21, 2026; a session occurring on May 26, 2026, that was not documented until June 3, 2026; sessions occurring on June 16, 2026, June 23, 2026 and June 30, 2026 that were not documented until July 19, 2026; a session occurring on July 7, 2026, that was not documented until July 20, 2026; and a session occurring on July 21, 2026, that was not documented until July 30, 2026. This is a repeat citation from the October 28, 2025, annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Cited finding
Clients #1, #2, #3, #4, and #6 had progress notes entered beyond the facility's 24-hour policy. This repeats the October 28, 2025 citation.
Accountable staff
All treating clinicians and Clinical Supervisor; billing verifies documentation; Compliance audits timeliness.
Plan of correction
Correct the identified deficiency. By November 5, the supervisor will review the five cited records and every active clinician's outstanding notes. Existing late notes will remain intact with their true timestamps. Missing records will be completed only by an appropriate author with reliable supporting information, clearly marked as late entries; unverifiable services will be referred to Compliance and billing for resolution.
Change the process. Effective October 30, each clinician will complete and authenticate progress notes within 24 elapsed hours after service, including services before weekends or holidays. Same-day completion will be the operational goal. Schedules will include documentation time. A daily reconciliation of attended visits and authenticated notes will identify missing, draft, unsigned, and late notes; required co-signatures will be tracked separately.
Implement and sustain. By November 5, staff will demonstrate note completion and escalation procedures. Supervisors will review the exception list each operating day and escalate overdue notes immediately. During EM downtime, staff will use approved secure documentation with the actual service and creation times, then enter or attach it when access returns. Billing will not release a claim without adequate authenticated supporting documentation. By November 12, Compliance will verify backlog disposition and workflow operation.
Monitoring and prevention of recurrence
The supervisor will reconcile 100% of services daily; Compliance will review timeliness weekly for 90 days and monthly thereafter. Target 100% authenticated within the facility's 24-hour standard. Reports will show the number due, on time, late, and missing. Repeated lateness triggers a written performance plan, protected documentation time, and workload or coverage adjustments.
Evidence of implementation
Note-timeliness report; backlog resolution; staff instruction; billing clearance; downtime procedure; performance follow-up. The 24-hour deadline is the facility policy cited by DDAP, not wording supplied by §709.93 itself.
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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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information entered within 7 days of the client's discharge, per the facility's policy, in two out of three applicable records reviewed.Client #4 was admitted on November 16, 2025, and was discharged April 28, 2026. There was no 7-day follow-up contact information documented in the client record at the time of the inspection.Client #5 was admitted on February 3, 2026, and was discharged July 7, 2026. There was no 7-day follow-up contact information documented in the client record at the time of the inspection.This is a repeat citation from the October 28, 2025, annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Cited finding
Clients #4 and #5 had no documented follow-up within seven days of discharge under the policy identified in the report. This repeats the October 28, 2025 citation.
Accountable staff
Discharging clinician and Clinical Supervisor; assigned backup covers staff absence.
Plan of correction
Correct the identified deficiency. By November 5, the supervisor will review Clients #4 and #5 for authentic follow-up evidence. If absent, the assigned clinician will assess whether a respectful, privacy-safe delayed contact is appropriate and attempt it using permitted contact methods. The record will show the actual date, result, and that the original deadline was missed. Staff will not present a current call as a timely historical contact.
Change the process. By November 5, every discharge will generate a task assigned to the primary clinician and backup, due within seven calendar days. The first attempt will be targeted by day 3, with further appropriate attempts before day 7 if needed. At discharge, staff will verify contact preferences and document aftercare arrangements. Follow-up will record date, method, outcome or unsuccessful attempt, client-reported status when reached, continuing care, and any action taken.
Implement and sustain. Staff will use discreet messages consistent with consent and privacy rules. Refusal, invalid contact information, or inability to reach the client will be documented without implying successful contact. The supervisor will review upcoming and overdue tasks at least twice weekly. By November 12, all Harrisburg discharges since October 28, 2025 will be audited for follow-up and assigned appropriate remediation. The controlled policy will expressly use seven calendar days to meet the cited seven-day standard.
Monitoring and prevention of recurrence
The supervisor will audit 100% of discharges weekly for 90 days, then monthly, with twice-weekly deadline checks continuing. Target 100% documented follow-up contact or appropriate attempts within seven calendar days. Any missed deadline prompts immediate assignment, current documentation, and a process review. Successful contact rates will be tracked separately from timely attempts.
Evidence of implementation
Cited-record reviews; delayed outreach records if appropriate; discharge task register; revised policy; backup assignments; follow-up audit results.
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