INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 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, Gensis 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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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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three of the seven records reviewed. Client #1 was admitted on March 07, 2025, and was still active at the time of the inspection. There was documentation that information was disclosed to the funding source on March 07, 2025, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.Client #5 was admitted on admitted on February 07, 2025, and discharged on July 15, 2025. There was documentation that information was disclosed to the funding source on February 07, 2025, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.Client #6 was admitted on March 31, 2025, and was still active at the time of the inspection. There was documentation that information was disclosed to the funding source on March 31, 2025, however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The three affected client records identified during the inspection were reviewed by the Clinical Leadership Staff and the Executive Director. For the two active clients (Client #1 and Client #6), signed informed and voluntary consents for disclosure were obtained and placed in the records. For the discharged client (Client #5), the record was documented with a corrective annotation noting the absence of consent at the time of discharge. The intake and disclosure workflow was revised to require a signed informed and voluntary consent prior to any release of information to funding sources. All intake, administrative, and clinical staff were informed of the change during supervision/managment meeting. In addition a formal retrain by 1/15/2026 on confidentiality and disclosure requirements, and supervisory verification is now required before any external disclosure occurs. This corrective action will be fully implemented by 1/15/2026. |
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 review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record, which included the specific information to be disclosed in two out of seven records reviewed. Client #2 was admitted on February 13, 2025, and discharged on September 09, 2025. A release of information form to an emergency contact, was signed and dated on February 13, 2025; however, it did not include the specific information to be disclosed.Client #7 was admitted on April 07, 2025, and was still active at the time of the inspection. A release of information form for an emergency contact, was dated and signed on April 07, 2025; however, it did not include the specific information to be disclosed. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Genesis House reviewed the two affected client records identified during the inspection. For the active client (Client #7), the release of information was updated to include the specific information authorized for disclosure. For the discharged client (Client #2), the record was documented with a corrective annotation noting the incomplete release at the time of discharge. The release of information form was revised to require completion of the "specific information to be disclosed" section prior to acceptance. All intake and clinical staff were retrained on proper completion of release forms, and supervisory verification is now required before any disclosure occurs. This corrective action will be fully implemented by January 15, 2026. Clinical Leadership Staff will conduct monthly chart audits and supervisory verification of properly completed releases of information prior to any disclosure. Quarterly compliance reviews by Compliance Officer will ensure continued adherence. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in three out of seven records reviewed.Client #2 was admitted on February 13, 2025, and discharged on September 09, 2025. An informed and voluntary consent from the client for the disclosure of information to a family member and outside counselor were signed and dated February 13, 2025, that did not include the purpose of disclosure. Client #3 was admitted on December 9, 2024, and discharged July 07, 2025. An informed and voluntary consent from the client for the disclosure of information to the emergency contact was signed and dated December 9, 2024, that did not include the purpose of disclosure. Client #7 was admitted on April 7, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to the emergency contact was signed and dated April 07, 2025, that did not include the purpose of disclosure. These findings were reviewed with facility staff during licensing process.
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Plan of Correction
A review of the three affected client records identified during the inspection. For the active client (Client #7), the informed and voluntary consent was updated to include the documented purpose of disclosure. For the two discharged clients (Clients #2 and #3), the records were annotated to reflect the missing purpose of disclosure at the time of service. The informed consent form was revised to require completion of the purpose-of-disclosure section prior to acceptance. All intake and clinical staff will be retrained on proper completion of consent forms, and supervisory verification is now required before any disclosure occurs. This corrective action will be fully implemented by December 12, 2025. Clinical Staff will be monitored by Clinical Leadership Staff through monthly chart audits and supervisory verification of properly completed informed consents prior to any disclosure. Quarterly compliance reviews by Compliance Officer will ensure continued adherence.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in two out of seven client records reviewed. Client #3 was admitted on December 9, 2024 and discharged on July 7, 2025. Consent forms were signed and dated December 9, 2024, for a family member, probation, funding source, and medical assistance that did not have documentation that the client was offered a copy of the consent form.Client #5 was admitted on February 7, 2025, and discharged on July 15, 2025. A consent form was signed and dated March 27, 2025, for children and youth that did not have documentation that the client was offered a copy of the consent form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Leadership and Executive Director reviewed the affected client records and confirmed that the two cited clients were discharged at the time of review; therefore, updated consents could not be re-executed for those specific individuals. An updated the consent form is to include a mandatory "copy offered to client" acknowledgment checkbox. This revised consent form is now required for all new admissions and active clients. All active client records were reviewed, and updated consents were completed for any active clients missing the acknowledgment. All intake and clinical staff will be retrained on the revised consent requirements by 1/20/26. The Clinical Director is responsible for ensuring that the corrective action is fully implemented and maintained. Compliance will be monitored through quarterly consent audits conducted by the Compliance Department, with supervisory verification by the Clinical Director to ensure that all consents include documentation that a copy was offered to the client. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation within 72 hours of intake, per facility policy, in three out of seven records reviewed. Client #1 was admitted on March 7, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than March 10, 2025; however, it was not completed until April 4, 2025. Client #3 was admitted on December 9, 2024, and discharged on July 7, 2025. A psychosocial evaluation was due no later than December 12, 2024; however, it was not completed until December 13, 2024. Client #5 was admitted on February 7, 2025, and discharged on July 15, 2025. A psychosocial evaluation was due no later than February 10, 2025; however, it was not completed until February 17, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Leadership staff and Executive Director reviewed the three affected client records identified during the inspection. For the active client (Client #1), the psychosocial evaluation was completed and placed in the record. For the two discharged clients (Clients #3 and #5), the records were annotated to reflect late completion at the time of service. An intake checklist was implemented to ensure psychosocial evaluations are completed within the alotted admission time. All clinicians were retrained on intake and psychosocial documentation timeframes, and supervisory oversight is now required prior to closing the intake process. The Clinical Director is responsible for ensuring full implementation of this corrective action. This corrective action has been fully implemented by November 30, 2025. Monitored through weekly intake audits conducted by the Clinical Director and monthly chart audits conducted by the Compliance Department to verify that psychosocial evaluations are completed within the alotted timeframe of intake. Quarterly compliance reviews will ensure continued adherence. |
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 develop and include written documentation that an individual treatment and rehabilitation plan was created with the client, by the third session, per facility policy, in five out of seven records reviewed.Client #1 was admitted on March 7, 2025 and was still active at the time of the licensing inspection. Client #1 had documentation of the start of an individual treatment plan in the record; however, there was no date nor a client signature or documentation to reflect it was created with the client or completed.Client #4 was admitted on January 13, 2025, and was still active at the time of the inspection. A treatment and rehabilitation plan was due to be completed by the third session which occurred on February 7, 2025, however, there was no written documentation it was developed with the client until September 22, 2025. Client #5 was admitted on February 7, 2025, and discharged on July 15, 2025. A treatment and rehabilitation plan was due to be completed by the third session which occurred on March 6, 2025, however, there was no written documentation it was developed with the client until May 15, 2025. Client #6 was admitted on March 31, 2025, and was still active at the time of the inspection. A treatment and rehabilitation plan was due to be completed by the third session which occurred on April 15, 2025, however, there was no written documentation it was developed with the client until September 05, 2025. Client #7 was admitted on April 7, 2025, and was still active at the time of the inspection. Client #7 had documentation of the start of an individual treatment plan in the record; however, there was no date nor a client signature or documentation to reflect it was created with the client or completed.This is a repeat citation from the October 08, 2024, licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A reviewed all affected client records and ensured that individual treatment and rehabilitation plans were completed, dated, and signed to reflect development with the client. The treatment plan workflow was reinforced to require completion by the third session in accordance with agency policy. EHR alerts were implemented to notify clinicians and supervisors of upcoming and overdue treatment plans. All clinical staff are to retrained on treatment planning timelines and documentation requirements, and supervisory review is now required to verify completion by the third session. Monitored through weekly supervisory review of treatment plan due-date reports and monthly chart audits to verify timely completion, signatures, and client involvement by the Clinical Directors. The Compliance Officer oversee quarterly compliance reviews will ensure sustained adherence and address any repeat deficiencies. All to be implemented by 12/12/2026. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, per facility policy, in seven of seven records reviewed. Client #1 was admitted on March 7, 2025, and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on March 10, 2025, April 15, 2025, June 10, 2025, July 23, 2025, and September 24, 2025, that were not completed until March 17, 2025, April 18, 2025, June 20, 2025, July 28, 2025, and October 23, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on April 23, 2025, and July 2, 2025, that were not completed until April 28, 2025, and October 14, 2025, respectively. Client #2 was admitted on February 13, 2025, and was discharged on September 9, 2025. The record contained progress notes for individual sessions occurring on March 13, 2025, April 22, 2025, and May 6, 2025, that were not completed until March 17, 2025, May 5, 2025, and May 14, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on March 20, 2025, and May 19, 2025, that were not completed until April 4, 2025 and May 24, 2025, respectively.Client # 3 was admitted on December 9, 2024 and was discharged on July 7, 2025. The record contained a progress note for individual session occurring on January 16, 2025, that was not completed until January 21, 2025. Client #4 was admitted on January 13, 2025 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on August 25, 2025, that was not completed until September 8, 2025. Additionally, the record contained a progress note for a group session occurring on March 26, 2025, that was not completed until April 19, 2025. Client #5 was admitted on February 7, 2025 and was discharged on July 15, 2025. The record contained progress notes for individual sessions occurring on February 7, 2025, March 6, 2025, March 20, 2025, April 25, 2025, and May 15, 2025, that were not completed until February 19, 2025, March 16, 2025, April 1, 2025, May 2, 2025, and June 30, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on March 20, 2025, March 27, 2025, and April 24, 2025, that were not completed until April 4, 2025, April 4, 2025, and April 30, 2025, respectively. Client #6 was admitted on March 31, 2025, and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on May 15, 2025, June 11, 2025, August 14, 2025, and September 5, 2025, that were not completed until May 20, 2025, July 24, 2025, September 24, 2025, and October 16, 2025, respectively. Client #7 was admitted on April 7, 2025, and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on June 24, 2025, August 12, 2025, August 25, 2025, and September 8, 2025, that were not completed until July 8, 2025, September 15, 2025, and September 15, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on April 22, 2025, May 22, 2025, June 17, 2025, June 24, 2025, July 9, 2025, July 15, 2025, July 16, 2025, July 30, 2025, August 12, 2025, August 13, 2025, August 25, 2025, August 27, 2025, September 3, 2025, September 8, 2025, September 10, 2025, September 17, 2025, September 24, 2025, and October 1, 2025, that were not completed until May 7, 2025, October 14, 2025, June 23, 2025, July 8, 2025, October 10, 2025, October 10, 2025, October 10, 2025, October 10, 2025, October 10, 2025, October 10, 2025, October 10, 2025, September 15, 2025, October 10, 2025, September 17, 2025, September 15, 2025, September 17, 2025, October 1, 2025, October 24, 2025, and October 7, 2025, respectively. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will use an EHR generated report during supervision with clinicians to ensure overdue notes are addressed. Clinicians and Supervisors will be retrained regarding progress note review. Daily compliance reports monitored by Clinical Supervisor. All to be implemented by 2/10/2026. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within 72 hours of discharge, per facility policy, in two out of three applicable records reviewed. The facility policy also indicates within 30 days of last appointment the record is closed and client discharged.Client #3 was admitted on December 9, 2024, and was discharged on July 7, 2025. The client was apprehended on March 04, 2025 and did not return to treatment; and the record was not closed until July 7, 2025. The discharge summary was not completed until July 07, 2025, the record should have been closed and client discharged on April 4, 2025, indicating the discharge summary would be completed by April 7, 2025. Client #5 was admitted on February 07, 2025, and was discharged on July 15, 2025. A discharge summary was due no later than July 22, 2025; however, it was not completed until July 23, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A full review of the records for Client #3 and Client #5. The delayed discharge summaries were completed and confirmed in the EHR.To prevent recurrence, the Electronic Health Record (EHR) has been updated to require completion of the discharge summary before a client record can be closed. This system control was implemented to ensure that all discharge summaries are finalized within the alotted timeframe of discharge. All clinical staff are to received mandatory retraining on discharge procedures, record closure timelines, and discharge summary documentation record closure timelines, and discharge summary documentation requirements. This training is to be completed by January 18, 2026. The Clinical Supervisor is responsible for ensuring that discharge summaries are completed timely. The Clinical Directors is responsible for overseeing implementation and ongoing compliance. A Discharge Documentation Audit has been implemented and is conducted by the Clinical Supervisor, with results reviewed monthly by the Executive Director. All corrective actions will be fully implemented as of January 18, 2026 is responsible for overseeing implementation and ongoing compliance. A Discharge Documentation Audit has been implemented and is conducted by the Clinical Supervisor, with results reviewed monthly by the Executive Director. Monitoring through discharge documentation audits conduct by the Clinical Leadership, with supervisory verification that discharge summaries review are completed within the designated timeframe for all future discharges. Immediate corrective action for any late documentation. Monthly supervisory will be conducted by Clinical Director. Quarterly reviews will ensure ongoing adherence by the Compliance Officer. |
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 document follow up information within 1 week following discharge in one of three applicable records. Client #5 was admitted on February 07, 2025, and was discharged on July 15, 2025. The follow up was due no later than July 22, 2025; however, none was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Staff will be assigned to track follow-ups. Follow-Up Documentation Log created. Clinical Director will conduct monthly QA reviews implemented. All will be implemented by 1/22/2026. |