INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 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 Ministries, Inc. 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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709.25 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 a review of administrative information, the facility failed to provide an annual financial audit for the fiscal years July 1, 2023 through June 30, 2024 and July 1, 2024 through June 30, 2025. This finding was reviewed with the facility staff during the licensing process. This is a repeat citation from the September 24, 2025 and December 19-20, 2024 annual licensing inspections.
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Plan of Correction
An administrative meeting was held on October 7, 2026, with the Facility Director, Project Director, CFO, and Financial Director to review the cited deficiency regarding annual financial audits and establish corrective actions to ensure ongoing compliance. The facility will work collaboratively with its contracted Certified Public Accountant (CPA) to establish completion dates for each outstanding fiscal year audit and implement a process for monitoring progress, maintaining documentation, and ensuring timely completion of future audits.
Fiscal Year July 1, 2023, through June 30, 2024:
Facility staff and the contracted CPA have agreed that the annual financial audit for the fiscal year July 1, 2023, through June 30, 2024, will be completed by March 1, 2027. Upon completion, the audit will be maintained in the facility's administrative records and made available for review upon request and during future licensing inspections.
Fiscal Year July 1, 2024, through June 30, 2025:
Facility staff and the contracted CPA have worked to establish a completion date of December 30, 2026 for the annual financial audit for the fiscal year July 1, 2024, through June 30, 2025. Upon completion, the audit will be maintained in the facility's administrative records and made available for review upon request and during future licensing inspections.
Ongoing Corrective Actions and Compliance Monitoring:
The Facility Director will establish and maintain a Plan of Correction compliance tracking log to document each fiscal year audit, the applicable completion date, progress updates, and confirmation of receipt of the completed audit. The Facility Director will be responsible for maintaining the log, conducting routine compliance checks and updates, and coordinating follow-up communication with the contracted CPA, in conjunction with the CFO, to obtain necessary progress updates and ensure compliance with established deadlines.
The Facility Director, CFO, and Project Director will collaborate with the contracted CPA to develop and implement a plan for completing all future annual financial audits by June 30 of the year following the applicable fiscal year-end. This process will include establishing anticipated completion dates, monitoring audit progress, and addressing delays as necessary to support timely completion.
The Facility Director will oversee ongoing implementation of these corrective measures and maintain documentation demonstrating compliance with 28 Pa. Code § 709.25. Completed annual financial audits will be retained in the facility's administrative records and made available for review upon request and during future licensing inspections.
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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 applicable client records reviewed, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on the signed consent forms in three of seven records.Client #1 was admitted on March 24, 2026 and was still active at the time of the inspection. An informed and voluntary consent was signed and dated March 24, 2026; however, it did not include the name of the person, agency, or organization to whom disclosure is made.Client #2 was admitted on April 21, 2026 and was still active at the time of the inspection. Two informed and voluntary consents were signed and dated April 21, 2026; however, they did not include the name of the person, agency, or organization to whom disclosure is made.Client #3 was admitted on June 3, 2026 and was still active at the time of the inspection. An informed and voluntary consent was signed and dated June 8, 2026; however, it did not include the name of the person, agency, or organization to whom disclosure is made.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 09/28/2026, an administrative meeting was held with the Facility Director, Project Director and CFO to review the cited Plan of Correction deficiencies and discuss corrective actions moving forward. As a result of this meeting, the Facility Director began implementing corrective measures to improve accuracy, accountability, and completion of required consent documentation.
On 09/29/2026, the Facility Director created and implemented new informed and voluntary consent/release authorization forms with clearly marked and fillable fields to ensure that the required person, agency, or organization to whom information may be disclosed is documented on each consent. The revised forms were also updated to include a refusal section for circumstances in which a client declines to complete or sign a consent form. The forms were revised to provide greater structure, consistency, and accountability for both staff and clients.
Effective 09/29/2026, a two-person verification process was implemented for all consent/release authorization forms. The staff member completing or obtaining the consent will complete the form, and a second staff member will review the completed consent for accuracy and completeness prior to the form being initialed off and filed in the client's record. The second staff member will specifically verify that the person, agency, or organization to whom disclosure is authorized is appropriately identified and that the required consent information has been completed. This two-part review process is intended to provide an additional level of accountability and prevent documentation errors before a consent is placed in the client's record.
The revised consent requirements and the new two-person verification process were reviewed with administration staff on 09/29/2026 during a staff training. Staff were instructed regarding the use of the revised forms, required documentation, expectations for completing and reviewing consent forms, the refusal documentation process, and the requirement that consents be reviewed for accuracy prior to being filed in the client's record.
As an immediate corrective action, Clients #1, #2, and #3 were provided with and completed new consent/release authorization forms containing the required disclosure recipient information. The previously completed consent forms were marked as superseded/non-active and retained in the respective client records for documentation purposes. The superseded forms will not be used for future disclosures, as noted. The affected clients were informed that the previous consent forms were no longer active and were informed of the need to complete and sign the revised consent forms.
The revised consent forms and two-person verification process were implemented effective 09/29/2026 and will continue to be utilized for all applicable consent/release authorization forms going forward. The Facility Director, in conjunction with additional administration staff will conduct periodic reviews of client records to verify continued compliance and will document the results of those reviews and any corrective action taken. The Facility Director will have overall responsibility for monitoring implementation of this corrective action and ensuring accountability for continued compliance.
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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 administrative information, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for the annual financial audit was submitted and approved by the Department for the September 24, 2025 and December 19-20, 2024 annual licensing inspections. The annual financial audit was again found to be a deficiency in the September 23, 2026 annual licensing inspection.This was reviewed with the facility staff during the licensing process.
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Plan of Correction
On 09.29.2026 and 10.07.2026, facility staff meetings were held to address identified POC deficiencies and communicate corrective actions to ensure that all Department-approved Plans of Correction are followed and completed within the established timeframes. These meetings were followed by the initiation of facility-wide corrective changes. Internal POC compliance tracking systems were implemented by the Facility Director and discussed with facility staff to ensure that staff are knowledgeable of identified deficiencies, required corrective actions, assigned responsibilities, and applicable deadlines.
Beginning 09.29.2026, staff training was initiated regarding identified compliance needs, beginning with the implementation and proper completion of the facility's revised release/consent authorizations. Staff will continue to receive training and updates regarding compliance requirements, facility-wide deadlines, and individualized responsibilities through Workplace Chat, weekly staff meetings, and the staff bulletin board. This communication process will be used to ensure that staff are made aware of identified errors or deficiencies, changes to procedures, upcoming deadlines, and expectations for maintaining compliance.
The Facility Director will maintain and oversee internal compliance tracking logs identifying applicable POC requirements, responsible staff, deadlines, status, and documentation of completion. Monthly monitoring and random chart audits will be conducted going forward to assess whether required corrective actions are being followed by staff and whether documentation demonstrates compliance. Findings from monitoring and chart audits will be reviewed by the Facility Director and communicated to staff as appropriate.
When errors, missed deadlines, or other instances of non-compliance are identified, the Facility Director will address the issue with the responsible staff member and provide individualized follow-up and additional training as necessary. Staff have been informed that continued or repeated non-compliance may result in additional individualized training, increased follow-up and monitoring, and potential corrective action when internal compliance issues persist. This process is intended to identify and address issues promptly rather than allowing deficiencies to continue or recur.
The facility's staff meeting structure will also be modified to better support the identification and monitoring of compliance deadlines, accuracy of business and administrative requirements, and completion of clinical documentation. POC-related updates, outstanding requirements, and applicable staff responsibilities will be communicated through the established staff communication processes to promote consistent understanding and accountability.
The Facility Director in conjunction with the CFO will be responsible for overseeing the internal POC tracking system, conducting or coordinating monthly monitoring and random chart audits, implementing additional training when needed, and ensuring that communication of compliance requirements and expectations remains consistent among facility staff. The Facility Director will also monitor completion of corrective actions and address identified barriers or concerns to ensure continued compliance and accountability.
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