INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2025, 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 year July 1, 2023 through June 30, 2024. This finding was reviewed with the facility staff during the licensing process. This is a repeat citation from the December 19-20, 2024 annual licensing inspection.
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Plan of Correction
In a meeting on September 25, 2025 with CFO, Financial Director, Facility Director, Project Director, and Certified CPA, it was determined that the financial audit for the fiscal year 2023-2024 will be completed by February 2026.
The Finacial Director and CFO will be responsible for making sure audits are complete. The Financial Director and CFO will also be responsible for maintaining communication with the Certified CPA regarding 2023-2024 financial audit documentations. |
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 a review of client records, the facility failed to document what specific information could be disclosed on a consent to release information form in one of seven records.Client #1 was admitted on January 30, 2025, and discharged on July 17, 2025. A release of information form was signed and dated by the client on January 30, 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In a meeting on September 25, 2025, staff members discussed consent to release information forms. All staff members were retrained on the process of filling out a consent to release information form by facility director.
Staff members have decided to enter a 3-part check system. The intake coordinator, facility director, and one additional administration staff member will check consents for accuracy during monthly file audits. Facility director will ensure accuracy of consent forms. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 30 days in five of six applicable records.Client #1 was admitted on January 30, 2025, and discharged on July 17, 2025. A treatment plan update was completed on April 30, 2025, and the next update was due no later than May 30, 2025; however, it was completed on June 3, 2025. Client #4 was admitted on April 7, 2025, and discharged on August 4, 2025. A treatment plan update was completed on June 6, 2025, and the next update was due no later than July 6, 2025; however, it was completed on July 7, 2025. Client #5 was admitted on August 14, 2025, and was still active at the time of the inspection. An initial treatment plan was created on August 14, 2025, an update was due no later than September 14, 2025; however, it was not completed until September 15, 2025.Client #6 was admitted on May 5, 2025, and was still active at the time of the inspection. A treatment plan update was completed on June 5, 2025, and the next update was due no later than July 5, 2025; however, it was completed on July 7, 2025. Client #7 was admitted on April 3, 2025, and was still active at the time of the inspection. A treatment plan update was completed on July 6, 2025, and the next update was due no later than August 6, 2025; however, it was completed on August 7, 2025. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A meeting was held on September 25, 2025, by Facility Director with Clinical and Administration staff to discuss the accuracy of treatment plans. Facility Director discussed with employees that all treatment plans must be completed on or before the 30th day from the last treatment plan.
Clinical staff members will ensure that when completing monthly treatment plans, they are dated on or before 30 days from the last treatment plan. These treatment plans with be checked for accuracy by the assigned counselor and also during monthly audits by Intake Coordinator, Facility Director, and one additional administration staff member. Current clients will be checked for accuracy during the next monthly audit beginning October 2025. |