D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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GENESIS HOUSE - BLOOMSBURG
823 CENTRAL ROAD
BLOOMSBURG, PA 17815

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Survey conducted on 10/27/2025

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on October 27, 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-Bloomsburg 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:	Plan of Correction
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.
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 records reviewed. Client #3 was admitted on March 26, 2025, and was still active at the time of the inspection. A consent form signed and dated March 25, 2025, for probation, did not have documentation that the client was offered a copy of the consent form.Client #6 was admitted on November 06, 2024, and was discharged on May 16, 2025. A consent form signed and dated March 05, 2025, for an outside provider, 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.	Plan of Correction A review of the affected client records and ensured that all active clients with missing consent copy documentation specifically Client #3 completed new consent forms that include acknowledgment that a copy was offered. (Client #6 is discharged; the record was annotated and corrected.)The facility revised the Consent Form to include a mandatory "Copy Offered to Client" checkbox, and the consent workflow was updated to require completion of this field prior to acceptance. All intake and clinical staff will be retrained on the updated consent requirements and the revised SOP. The Clinical Supervisor is responsible for ensuring implementation of all corrective actions and verifying proper consent documentation going forward. This corrective action was fully implemented as of January 20, 2026. Monitoring through monthly chart audits conducted by the Clinical Supervisor and quarterly consent audits to ensure ongoing adherence by the Compliance Officer. Supervisors will review consent documentation for all newly admitted clients to confirm proper completion, including the "Copy Offered" acknowledgment.
709.91(b)(6) LICENSURE Intake and admission 709.91. Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation.
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 six out of seven records reviewed. Client #2 was admitted on February 11, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than February 14, 2025; however, it was not completed until February 20, 2025. Client #3 was admitted on March 26, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than March 29, 2025; however, it was not completed until March 31, 2025.Client #4 was admitted on February 20, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than February 23, 2025; however, it was not completed until February 25, 2025. Client #5 was admitted on November 26, 2024, and was discharged on June 16, 2025. A psychosocial evaluation was due no later than November 29, 2024; however, it was not completed until December 03, 2024. Client #6 was admitted on November 06, 2024, and was discharged on May 16, 2025. A psychosocial evaluation was due no later than November 09, 2024; however, it was not completed until November 11, 2024.Client #7 was admitted on April 16, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 19, 2025; however, it was not completed until May 12, 2025. This is a repeat citation from October 09, 2024 licensing inspection.These findings were reviewed with facility staff during the licensing process.	Plan of Correction A review of all six affected client records identified during the inspection. For the four active clients (Clients #2, #3, #4, and #7), psychosocial evaluations have been completed, updated as needed, and placed in the client records. For the two discharged clients (Clients #5 and #6), the records were annotated to reflect delayed completion at the time of service. An Intake Checklist was implemented to ensure psychosocial evaluations are completed within the alotted timeframe of admission per facility policy. All clinicians were retrained on intake documentation timeframes. Supervisory oversight is now required prior to finalizing the intake process. Weekly intake audits were initiated to prevent recurrence. The Clinical Director is responsible for ensuring full implementation and ongoing compliance with this corrective action. This corrective action will be fully implemented by January 30, 2026. Monitoring through weekly intake audits conducted by the Clinical Director and monthly chart audits conducted by the Compliance Department to verify psychosocial evaluations are completed within the alotted timeframe. Quarterly compliance reviews will ensure sustained adherence.
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.
Observations Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in six out of seven records reviewed. Client #1 was admitted on December 31, 2024, and was discharged on July 10, 2025. A comprehensive treatment plan was completed on January 02, 2025, and an update was due no later than March 02, 2025; however, it was not completed until June 05, 2025.Client #2 was admitted on February 11, 2025 and was still active at the time of the inspection. A treatment plan update was completed on April 30, 2025, and the next update was due no later than June 30, 2025; however, it was not completed until August 12, 2025. Client #3 was admitted on March 26, 2025 and was still active at the time of the inspection. A treatment plan update was completed on June 11, 2025, and the next update was due no later than August 11, 2025; however, it was not completed until October 15, 2025. Client #5 was admitted on November 26, 2024 and was discharged on June 16, 2025. A comprehensive treatment plan was completed on December 09, 2024, and an update was due no later than February 09, 2025; however, it was not completed until March 04, 2025. Additionally, the next update was due no later than May 04, 2025; however, there was no documentation it was completed. Client #6 was admitted on November 06, 2024 and was discharged on May 16, 2025. A treatment plan update was completed on February 05, 2025, and the next update was due no later than April 06, 2025; however, there was no documentation it was completed. Client #7 was admitted on April 16, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 28, 2025, and an update was due no later than June 28, 2025; however, it was not completed until July 30, 2025.These findings were reviewed with facility staff during the licensing process.	Plan of Correction A review of all six affected client records identified during the inspection. For the four active clients (Clients #2, #3, and #7), overdue treatment plan updates have been completed and placed in the client records. For the two discharged clients (Clients #1, #5, and #6), the records were annotated to reflect missed or delayed treatment plan updates at the time of service. EHR treatment plan alerts were activated at 45 and 55 days to prompt clinicians of upcoming 60-day update requirements. All clinical staff will be retrained on treatment plan update timelines and documentation standards. Biweekly treatment plan audits were initiated to ensure compliance.The Clinical Director is responsible for ensuring full implementation by February 1, 2026 and ongoing compliance with this corrective action. Monitoring through biweekly treatment plan audits conducted by the Clinical Director and monthly chart audits. Quarterly compliance reviews will ensure sustained adherence and prevent recurrence of delayed treatment plan updates by the Compliance Officer.
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.
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 within 24 hours after therapy sessions, unless session occurs on a Friday then completed within 72 hours, per facility policy, in seven of seven records reviewed.Client #1 was admitted on December 13, 2024, and was discharged on July 10, 2025. The record contained progress notes for individual sessions occurring on December 17, 2024, January 02, 2025, January 07, 2025, January 09, 2025, January 16, 2025, April 08, 2025, April 22, 2025, April 29, 2025, May 07, 2025, May 13, 2025, and May 27, 2025, that were not completed until January 28, 2025, January 28, 2025, April 06, 2025, February 13, 2025, January 21, 2025, May 15, 2025, June 17, 2025, June 17, 2025, May 28, 2025, May 26, 2025, and June 17, 2025. Additionally, the record contained progress notes for group sessions occurring on January 02, 2025, January 07, 2025, January 09, 2025, January 16, 2025, January 22, 2025, January 28, 2025, January 30, 2025, February 04, 2025, February 05, 2025, February 12, 2025, February 13, 2025, February 18, 2025, February 20, 2025, February 26, 2025, March 04, 2025, March 05, 2025, March 12, 2025, March 18, 2025, March 25, 2025, March 27, 2025, April 08, 2025, April 09, 2025, April 16, 2025, April 23, 2025, May 07, 2025, May 08, 2025, May 20, 2025, May 22, 2025, and May 27, 2025, that were not completed until January 28, 2025, April 09, 2025, April 09, 2025, April 09, 2025, April 09, 2025, April 28, 2025, April 09, 2025, April 09, 2025, April 08, 2025, April 08, 2025, April 08, 2025, May 28, 2025, May 28, 2025, April 28, 2025, April 08, 2025, May 01, 2025, April 08, 2025, April 08, 2025, May 01, 2025, May 07, 2025, April 07, 2025, April 29, 2025, May 28, 2025, May 14, 2025, May 27, 2025, May 27, 2025, June 17, 2025, June 17, 2025, June 17, 2025, and June 17, 2025, respectively. Client #2 was admitted on February 11, 2025, and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on March 18, 2025, April 01, 2025, April 15, 2025, April 22, 2025, April 23, 2025, April 29, 2025, April 30, 2025, May 05, 2025, May 06, 2025, May 08, 2025, May 12, 2025, May 13, 2025, May 27, 2025, May 28, 2025, June 03, 2025, June 17, 2025, June 24, 2025, July 01, 2025, July 03, 2025, July 08, 2025, July 10, 2025, August 18, 2025, August 19, 2025, August 21, 2025, September 02, 2025, September 03, 2025, September 09, 2025, September 11, 2025, September 16, 2025, September 23, 2025, September 30, 2025, October 7, 2025, October 14, 2025, and October 21, 2025, that was not completed until June 17, 2025, June 17, 2025, June 17, 2025, June 17, 2025, May 28, 2025, May 05, 2025, May 28, 2025, May 08, 2025, June 17, 2025, May 28, 2025, May 22, 2025, May 26, 2025, June 27, 2025, June 12, 2025, June 18, 2025, July 17, 2025, July 02, 2025, July 09, 2025, July 17, 2025, July 22, 2025, July 17, 2025, September 04, 2025, September 09, 2025, October 13, 2025, September 22, 2025, September 08, 2025, September 24, 2025, September 15, 2025, September 25, 2025, October 14, 2025, October 08, 2025, October 21, 2025, October 22, 2025, and October 24, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on February 27, 2025, April 10, 2025, April 17, 2025, May 15, 2025, May 29, 2025, August 18, 2025, August 21, 2025, August 25, 2025, and August 28, 2025, that were not completed until April 28, 2025, May 07, 2025, May 07, 2025, June 11, 2025, June 16, 2025, September 04, 2025, September 08, 2025, September 15, 2025, and September 18, 2025, respectively. Client #3 was admitted on March 26, 2025, and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on March 26, 2025, April 17, 2025, May 08, 2025, May 24, 2025, May 22, 2025, June 11, 2025, July 02, 2025, July 09, 2025, July 30, 2025, August 13, 2025, August 27, 2025, and September 17, 2025, that were not completed until April 02, 2025, May 20, 2025, May 30, 2025, May 23, 2025, June 04, 2025, June 11, 2025, July 17, 2025, July 17, 2025, July 17, 2025, August 11, 2025, October 13, 2025, October 13, 2025, and October 14, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on April 16, 2025, April 30, 2025, May 07, 2025, May 08, 2025, May 14, 2025, May 22, 2025, May 28, 2025, May 29, 2025, June 05, 2025, June 12, 2025, July 03, 2025, July 09, 2025, July 10, 2025, July 16, 2025, July 17, 2025, July 23, 2025, July 31, 2025, August 11, 2025, August 13, 2025, and October 08, 2025, that were not completed until May 14, 2025, May 27, 2025, May 27, 2025, May 23, 2025, May 27, 2025, May 28, 2025, June 16, 2025, July 22, 2025, July 22, 2025, July 22, 2025, July 22, 2025, July 29, 2025, August 11, 2025, July 30, 2025, August 11, 2025, September 19, 2025, September 25, 2025, and October 12, 2025, respectively. Client #4 was admitted on February 20, 2025, and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on February 20, 2025, February 26, 2025, March 13, 2025, April 07, 2025, April 16, 2025, May 13, 2025, April 15, 2025, April 29, 2025, June 03, 2025, July 10, 2025, October 01, 2025, and October 08, 2025, that were not completed April 08, 2025, April 08, 2025, April 08, 2025, April 17, 2025, May 27, 2025, May 28, 2025, June 17, 2025, June 17, 2025, June 18, 2025, July 28, 2025, October 14, 2025, and October 14, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on February 26, 2025, March 12, 2025, March 26, 2025, April 09, 2025, April 23, 2025, April 30, 2025, May 07, 2025, May 08, 2025, May 14, 2025, May 22, 2025, and May 28, 2025, that were not completed until , April 08, 2025, May 01, 2025, April 11, 2025, April 16, 2025, May 27, 2025, May 27, 2025, May 27, 2025, May 27, 2025, May 27, 2025, May 22, 2025, and June 16, 2025, respectively. Client #5 was admitted on November 26, 2025, and was discharged on June 16, 2025. The record contained progress notes for individual sessions occurring on December 16, 2025, December 30, 2025, January 23, 2025, February 11, 2025, February 18, 2025, and February 25, 2025, that were not completed until January 22, 2025, January 23, 2025, April 02, 2025, March 11, 2025, April 02, 2025, and March 11, 2025, respectively. Additionally, the record contained a progress note for a group session occurring on February 25, 2025, that was not completed until April 09, 2025. Client #6 was admitted on November 26, 2024, and was discharged on May 16, 2025.The record contained progress notes for individual sessions occurring on November 20, 2024, December 04, 2024, December 11, 2024, December 18, 2025, January 15, 2025, and January 22, 2025, that were not completed until November 27, 2025, December 13, 2025, December 19, 2025, January 22, 2025, March 14, 2025, April 02, 2025, and April 08, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on November 20, 2024, January 02, 2025, January 09, 2025, January 15, 2025, January 22, 2025, January 23, 2025, January 28, 2025, January 30, 2025, February 04, 2025, February 05, 2025, February 06, 2025, February 13, 2025, February 18, 2025, February 19, 2025, February 25, 2025, February 26, 2025, March 04, 2025, and March 05, 2025, that were not completed until December 11, 2024, April 09, 2025, April 09, 2025, April 02, 2025, April 09, 2025, April 09, 2025, April 28, 2025, April 09, 2025, April 09, 2025, April 08, 2025, April 28, 2025, May 28, 2025, May 28, 2025, April 08, 2025, April 08, 2025, April 28, 2025, April 28, 2025, April 08, 2025, and April 08, 2025, respectively. Client #7 was admitted on April 16, 2025, and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on April 16, 2025, April 23, 2025, April 24, 2025, May 22, 2025, June 09, 2025, June 17, 2025, July 01, 2025, August 05, 2025, July 30, 2025, and August 26, 2025, that were not completed until May 07, 2025, May 07, 2025, May 07, 2025, June 04, 2025, July 07, 2025, July 07, 2025, July 07, 2025, July 07, 2025, August 11, 2025, August 11, 2025, and October 09, 2025. Additionally, the record contained progress notes for group sessions occurring June 17, 2025, June 30, 2025, and July 17, 2025, that were not completed until July 29, 2025, July 31, 2025, and July 21, 2025, respectively. These findings were reviewed with facility staff during the licensing process. ``	Plan of Correction A review of all seven affected client records identified during the inspection. For all active clients, overdue progress notes have been completed and placed in the record; for discharged clients, records were annotated to reflect late completion at the time of service. The Clinical Supervisor now uses an EHR-generated documentation report during supervision with clinicians to identify and address overdue notes. All clinicians and supervisors will be retrained on the progress note timeliness requirement, and daily documentation compliance reports are now monitored by the Clinical Supervisor. This corrective action will be fully implemented by February 10, 2026. Ongoing compliance will be monitored through daily EHR documentation reports, weekly supervisory review with clinicians, and monthly chart audits by the Clinical Supervisor to ensure progress notes are completed within required timeframes and to prevent recurrence.
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.
Observations Based on a review client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project to include a discharge summary within 72 hours of discharge, per facility policy, in one out of three applicable records reviewedClient #1 was admitted on December 13, 2024 and was discharged on July 10, 2025. The discharge summary was due no later than July 13, 2025; however, it was not documented until August 15, 2025.This finding was reviewed with facility staff during the licensing process.	Plan of Correction A review of the affected discharged client record identified during the inspection. For Client #1, the record was annotated to reflect the late discharge summary at the time of service. The EHR has been updated to require completion of the discharge summary prior to chart closure. The Clinical Supervisor now uses an EHR-generated overdue discharge summary report during supervision with clinicians to ensure timely completion. All clinicians and supervisors will be retrained on the allotted timeframe of discharge summary requirement. The Clinical Supervisor is responsible for ensuring full implementation by January 18, 2026. Monitoring through discharge documentation monthly charts audits conducted by the Clinical Supervisor. Quarterly compliance reviews will be conducted 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.
Observations Based on review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project to include follow-up information one week following discharge, per facility policy, in two of three applicable records reviewed. Client #1 was admitted on December 31, 2024, and was discharged on July 10, 2025. Follow-up information was due to be documented no later than July 17, 2025; however, none was documented. Client #5 was admitted on November 26, 2024, and was discharged on June 16, 2025. Follow-up information was due to be documented no later than June 23, 2025; however, none was documented. This finding was reviewed with facility staff during the licensing process.	Plan of Correction A review of the discharged client records identified during the inspection. For Client #1 and Client #5, follow-up documentation was completed and added to the client record.To prevent recurrence, Administrative Support Staff have been assigned to track and document all required follow-ups using a newly created Follow-Up Documentation Log, which will be implemented program-wide. A mandatory staff retraining session on follow-up requirements and documentation standards. A Monthly QA Review process has been implemented to ensure that all follow-up requirements are met within the required timeframe. The Program Director is responsible for ensuring that the corrective actions are implemented and maintained fully implemented by January 22, 2026.Monitoring through monthly QA audits of discharged client records and review of the Follow-Up Documentation Log. The Program Director will address noncompliance immediately and implement corrective measures as needed.