INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 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, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of ten personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee #10 was hired on January 13, 2025, as a counselor assistant and is still current in that position. Employee #10 has a High School Diploma and may counsel clients only under the direct supervision of a trained counselor or clinical supervisor for at least the first three months of employment, and for the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #8 has documented supervision notes from January 22, 2025 - October 22, 2025, that failed to identify if direct or close observation were occurring. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A review ofthe personnel records for the affected counselor assistants identified during the inspection. Employee #10, who holds a high school diploma, was immediately placed under the required level of direct supervision in accordance, and supervision levels were clarified moving forward. The Counselor Assistant Supervision Log was implemented to clearly document "direct" versus "close" supervision for all counselor assistants. Employee #8's supervision documentation was corrected to reflect the appropriate supervision type. All supervisors were retrained on the supervision requirements. The Clinical Supervisor is responsible for ensuring implementation and ongoing compliance. This corrective action will be fully implemented by January 15, 2026. Monitored through weekly supervisory review of Counselor Assistant Supervision Logs and quarterly supervision audits conducted by the Compliance Department to ensure proper supervision levels are maintained based on education requirements. |
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 three out of seven client records reviewed. Client #2 was admitted on January 15, 2025, and was still active at the time of the inspection. A consent form signed and dated April 1, 2025, for an outside facility, did not have documentation that the client was offered a copy of the consent form.Client #3 was admitted on May 30, 2025, and discharged on September 15, 2025. A consent form signed and dated May 30, 2025, for a funding source and a hospital, did not have documentation that the client was offered a copy of the consent form. Client #7 was admitted on January 24, 2025, and was still active at the time of the inspection. A consent form signed and dated January 24, 2025, for a case manager, a funding source, and county probation, 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
A review of the three affected client records identified during the inspection. For the two active clients (Client #2 and Client #7), new consent forms were completed that include documentation confirming that a copy of the consent was offered to the client and a copy maintained in the record. For the discharged client (Client #3), the record was annotated to reflect the missing documentation at the time of service. The consent form was revised to include a mandatory "copy offered to client" checkbox. All intake and clinical staff were retrained on the revised consent process. The Clinical Director is responsible for ensuring full implementation by 1/20/26 and ongoing compliance with this corrective action. Compliance will be monitored through monthly chart audits conducted by the Compliance Department, with supervisory verification by the Clinical Director to ensure all consent forms 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 in client records, within 72 hours of intake, per facility policy in five out of seven records reviewed. Client #2 was admitted on January 15, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than January 18, 2025; however, it was not completed until February 04, 2025. Client #3 was admitted on May 30, 2025, and discharged on September 15, 2025. A psychosocial evaluation was due no later than June 02, 2025; however, it was not completed until June 05, 2025.Client #4 was admitted on January 25, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than January 28, 2025; however, it was not completed until January 31, 2025. Client #5 was admitted on April 07, 2025, and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 10, 2025; however, it was not completed until April 16, 2025. Client #6 was admitted on February 13, 2025, and was discharged on May 06, 2025. A psychosocial evaluation was due no later than February 16, 2025; however, it was not completed until March 17, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the five affected client records identified during the inspection. For the three active clients (Clients #2, #4, and #5), psychosocial evaluations have been completed and placed in the records. For the two discharged clients (Clients #3 and #6), 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 timeframe of admission per facility policy. All clinicians will be retrained on intake documentation timelines. Supervisory oversight is now required prior to closing the intake process. The Clinical Director is responsible for ensuring full implementation by 1/30/26 and ongoing compliance with this corrective action. Monitoring through weekly intake audits conducted by the Clinical Director and monthly chart audits conducted by the Compliance Officer to verify that psychosocial evaluations are completed within the alotted timeframe of intake. Quarterly compliance reviews will ensure continued 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.
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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 November 08, 2024, and was discharged on May 15, 2025. A comprehensive treatment plan was completed on December 04, 2024, and an update was due no later than February 04, 2025; however, it was not completed until February 18, 2025. Client #2 was admitted on January 15, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 18, 2025, and an update was due no later than May 18, 2025; however, it was not completed until June 16, 2025. Additionally, the next update was due no later than August 16, 2025; however, it was not completed until October 07, 2025. Client #4 was admitted on January 25, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 24, 2025, and an update was due no later than April 26, 2025; however, it was not completed until May 14, 2025. Additionally, the next update was due no later than July 14, 2025; however, it was not completed until September 08, 2025. Client #5 was admitted on April 07, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 01, 2025, and an update was due no later than July 01, 2025; however, it was not completed until July 07, 2025. Client #6 was admitted on February 13, 2025 and was discharged on May 06, 2025. A comprehensive treatment plan was completed on February 27, 2025, and an update was due no later than April 27, 2025; however, none was completed. Client #7 was admitted on January 24, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 12, 2025, and an update was due no later than April 13, 2025; however, it was not completed until April 26, 2025. This is a repeat citation from October 20, 2021, October 14, 2022, September 22, 2023, and October 09, 2024 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the six affected client records identified during the inspection. For the four active clients (Clients #2, #4, #5, and #7), all overdue treatment plan updates have been completed and placed in the records. For the two discharged clients (Clients #1 and #6), the records were annotated to reflect missed or late updates at the time of service. EHR reminders were activated at 45 and 55 days to alert clinicians of upcoming treatment plan update deadlines. An intake and treatment plan tracking checklist was implemented. All clinical staff will be retrained on the 60-day treatment plan update requirement. Biweekly treatment plan audits were initiated. The Clinical Director is responsible for ensuring full implementation and ongoing compliance with this corrective action. This corrective action will be fully implemented by February 2, 2026. Monitoring through biweekly treatment plan audits conducted by the Clinical Director and monthly chart audits conducted by the Compliance Officer. Quarterly compliance reviews will be completed to ensure sustained adherence and prevent recurrence of delayed treatment plan updates. |
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 within 24 hours after therapy sessions, unless session occurs on a Friday then completed within 72 hours, per facility policy, in six of seven records reviewed. Client #2 was admitted on January 15, 2025, and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on January 23, 2025, February 06, 2025, February 13, 2025, February 18, 2025, March 04, 2025, March 18, 2025, June 11, 2025, June 24, 2025, July 15, 2025, July 29, 2025, August 12, 2025, September 02, 2025, that were not completed until February 26, 2025, March 05, 2025, March 07, 2025, March 11, 2025, March 13, 2025, March 25, 2025, June 17, 2025, July 02, 2025, August 05, 2025, August 14, 2025, September 24, 2025, October 20, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on January 23, 2025, February 06, 2025, February 13, 2025, February 18, 2025, that were not completed until January 28, 2025, February 10, 2025, February 18, 2025, and February 25, 2025, respectively.Client #3 was admitted on May 30, 2025, and was discharged on September 15, 2025. The record contained progress notes for individual sessions occurring on June 21, 2025, August 02, 2025, August 09, 2025, that were not completed until July 08, 2025, August 06, 2025, September 15, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on July 09, 2025, July 12, 2025, July 23, 2025, July 30, 2025, that were not completed until July 15, 2025, July 29, 2025, July 28, 2025, and August 04, 2025, respectively.Client #4 was admitted on January 25, 2025, and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on January 25, 2025, and July 30, 2025, that were not completed until January 31, 2025, and August 04, 2025, respectively. Additionally, the record contained progress notes for group sessions occurring on February 05, 2025, May 28, 2025, July 09, 2025, July 30, 2025, August 04, 2025, August 06, 2025, August 11, 2025, and August 27, 2025, that were not completed until February 10, 2025, June 02, 2025, July 15, 2025, August 04, 2025, September 10, 2025, August 11, 2025, September 15, 2025, and September 02, 2025, respectively. Client #5 was admitted on April 07, 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 October 10, 2025. Client #6 was admitted on February 13, 2025, and was discharged on May 06, 2025. The record contained progress notes for individual sessions occurring on February 27, 2025, March 18, 2025, April 17, 2025, and April 24, 2025, that were not completed until March 03, 2025, March 26, 2025, April 21, 2025, and April 28, 2025, respectively.Client #7 was admitted on January 24, 2025, and was still active at the time of the inspection. The record contained progress notes for individual sessions occurring on May 08, 2025, May 15, 2025, May 31, 2025, June 28, 2025, July 26, 2025, and August 16, 2025, that were not completed until June 15, 2025, May 22, 2025, June 09, 2025, July 09, 2025, August 14, 2025, and September 26, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the six affected client records identified during the inspection. For the four active clients (Clients #2, #4, #5, and #7), all overdue progress notes have been completed and placed in the records. For the two discharged clients (Clients #3 and #6), the records were annotated to reflect late completion at the time of service. The Clinical Supervisor now uses an EHR-generated documentation compliance report during weekly supervision with clinicians to identify and resolve overdue notes. All clinicians and supervisors will be retrained on progress note completion requirements. The Clinical Supervisor is responsible for ensuring full implementation and ongoing compliance with this corrective action. This corrective action will be fully implemented by February 10, 2026. Monitoring through daily EHR documentation compliance reports, weekly supervisory review, and monthly chart audits conducted by the Compliance Officer. Quarterly compliance reviews will ensure sustained adherence and prevent recurrence. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to have complete client record on an individual which includes information relative to the client's involvement with the project that included aftercare information completed prior to discharge, per the policy manual, in three out of three applicable discharged records reviewed. Client #1 was admitted on November 08, 2024, and discharged on May 15, 2025. The client record did have aftercare information documented. Client #3 was admitted on May 30, 2025, and discharged on September 15, 2025. The client record did have aftercare information documented.Client #6 was admitted February 13, 2025, and discharged on May 06, 2025. The client record did have aftercare information documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Implemented a mandatory Discharge Checklist that requires completion and verification of aftercare planning prior to discharge. All clinical staff will beretrained on discharge documentation and aftercare requirements. Supervisory review of all discharge documentation is now required prior to chart closure. The Clinical Supervisor is responsible for ensuring full implementation and ongoing compliance with this corrective action. This corrective action was fully implemented as of January 25, 2026. Monitoring through monthly discharge audits conducted by the Compliance Officer, with supervisory verification to ensure aftercare plans are completed and documented prior to discharge. Quarterly compliance reviews will ensure continued adherence. |
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 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 November 08, 2024 and was discharged on May 15, 2025. A discharge summary was due no later than May 18, 2025; however, it was not documented until July 17, 2025. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Updated the EHR workflow to require completion of the discharge summary before a chart can be closed. All clinical staff will be retrained on the designateed timeframes for discharge summary requirement. Weekly discharge documentation audits were implemented to ensure compliance. The Clinical Supervisor is responsible for ensuring corrective actions are fully implemented and maintained. This corrective action was fully implemented as of January 18, 2026. Monitoring through weekly discharge documentation audits conduct by the Clinical Leadership, with supervisory verification that discharge summaries are completed within the designated timeframe for all future discharges. 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 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 one of three applicable records reviewed. Client #1 was admitted on November 08, 2024, and was discharged on May 15, 2025. Follow-up information was due to be documented no later than May 22, 2025; however, it was not documented until June 09, 2025. This finding was reviewed with facility staff during the licensing process.
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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 follow-up documentation at the time of discharge. An Administrative Staff Follow-Up Tracking System was implemented to ensure follow-up documentation is completed within one week of discharge in accordance with facility policy. A Follow-Up Documentation Log is now required for all discharges. All administrative and clinical staff will be retrained on follow-up documentation requirements. The Clinical Supervisor is responsible for ensuring full implementation and ongoing compliance with this corrective action. This corrective action was fully implemented as of January 22, 2026. Monitoring through monthly QA reviews of the Follow-Up Documentation Log conducted by the Clinical Supervisor, with supervisory verification to ensure follow-ups are documented within one week of discharge. Quarterly compliance reviews will ensure continued adherence by the Compliance Officer. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing and documenting treatment plan updates in the outpatient records was submitted and approved by the Department for October 20, 2021, October 14, 2022, September 22, 2023, and October 09, 2024, annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the October 24, 2025, licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A eview of the affected discharged client record identified during the inspection. For Client #1, the record was annotated to reflect the late follow-up documentation at the time of discharge. An Administrative Staff Follow-Up Tracking System was implemented to ensure follow-up documentation is completed within one week of discharge in accordance with facility policy. A Follow-Up Documentation Log is now required for all discharges. All administrative and clinical staff will be retrained on follow-up documentation requirements. The Clinical Supervisor is responsible for ensuring full implementation and ongoing compliance by February 1, 2026. Monitoring through monthly QA reviews of the Follow-Up Documentation Log conducted by the Clinical Supervisor, with supervisory verification to ensure follow-ups are documented within one week of discharge. Quarterly compliance reviews conducted by the Compliance Officer. |