INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Behavioral Health Systems 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 12, 2025. There was no documentation in the personnel record indicating the fire extinguisher training was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Attached is the Emergency Guidelines and Fire Extinguisher training certificate for the indicated employee. This was completed at hire.
The Emergency Guidelines training will occur during new employee orientation. Personnel records will be maintained digitally and monitored monthly for required trainings. Human Resources will email the Program Director a monthly tracking chart to ensure required trainings are completed or show what is coming due.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 12, 2025. There was no documentation in the personnel record indicating the training to perform assigned tasks during emergencies was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Environment of Care Representative will conduct Fire Drills during varied times so that staff on all shifts receive Fire Drill training. This will be reviewed monthly by the Program Director each month to ensure completion. This will start on 8/15/25.
Attached is the Emergency Guidelines and Fire Extinguisher training certificate for the indicated employee. This was completed at hire.
The Emergency Guidelines training will occur during new employee orientation. Personnel records will be maintained digitally and monitored monthly for required trainings. Human Resources will email the Program Director a monthly tracking chart to ensure required trainings are completed or show what is coming due. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's November 2024 through May 2025 fire drill logs, the facility failed to ensure a fire alarm or smoke detector was set off during each fire drill.
There was no documentation for every month reviewed that indicated a fire alarm or smoke detector was set off during each fire drill conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will meet with the landlord to determine if the fire alarm can be set off solely in our building.
The Program Director will submit a formal request to waive the requirement to set off the smoke detector due to sharing the building with another tenant.
Should this not be approved, the Program Director meet with the tenant of our shared building and inform him in advance of times we will conduct our fire drills and that the alarm will be set off.
The Program Director will review the monthly fire drill logs to ensure that either the alarm is being set off or the alternate device is being used. This will occur by 8/30/25.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of seven client records reviewed.
Client # 6 was admitted on February 7, 2025 and was discharged on March 25, 2025. The release of information forms to the funding source and the parole officer were completed on February 13, 2025; however, both forms did not include documentation of the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clients are provided a voluntary and informed consent at the start of treatment which is titled "Consent Acknowledgement 4.0." Clients are also provided with Releases of Information forms so that they agency may speak with others involved in treatment with the client's permission.
In order to ensure that all Consent Acknowledgement documents and Releases of Information are signed and completed on time, the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct 5 chart audits per month to verify completion.
All staff will be provided with re-training on consent and release documentation requirements for the need to obtain the Informed and Voluntary Consents at the start of treatment as well as to obtain signatures on all Releases of Information. Training will occur during individual and group supervision. This will occur by 8/15/25.
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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 document an individual treatment and rehabilitation plan, which is to be developed with the client, in five of six applicable client records reviewed.
The facility policy and procedure manual states the individual treatment and rehabilitation plan is to be completed within thirty days of admission.
Client # 1 was admitted on January 14, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than February 13, 2025; however, the plan was not completed until April 17, 2025.
Client # 3 was admitted on February 25, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than March 27, 2025; however, the plan was not completed until April 22, 2025.
Client # 4 was admitted on January 8, 2025 and was discharged on April 24, 2025. The individual treatment and rehabilitation plan was due to be completed no later than February 7, 2025; however, the plan was not completed until March 5, 2025.
Client # 6 was admitted on February 7, 2025 and was discharged on March 25, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
Client # 7 was admitted on January 27, 2025 and was discharged on May 12, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
2. In order to ensure that all Initial Treatment Plans are completed on time, the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct a chart audit to verify completion of the initial treatment plan when an intake is submitted for approval. This will be updated in the tracker.
All staff will be provided with re-training on documentation requirements regarding initial treatment planning and the goal of completing it during the intake. Training will occur during individual and group supervision. This will occur by 8/15/25.
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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 client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in one of three applicable client records reviewed.
Client # 2 was admitted on February 4, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 4, 2025 and an update was due no later than May 3, 2025; however, the update was not completed until May 15, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure that all Review Treatment Plans are completed every 60 days, the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct 5 chart audits per month to verify completion. The Program Coordinator will send monthly reminders to staff. This will begin on 8/1/25
All staff will be provided with re-training on documentation requirements regarding review treatment planning and the goal of completing it during the intake. Training will occur during individual and group supervision. This will occur by 8/30/25.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in four of five applicable client records reviewed.
The facility policy and procedure manual states there will be case consultations completed for all clients every 90 days.
Client # 1 was admitted on January 14, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 2 was admitted on February 4, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 4 was admitted on January 8, 2025 and was discharged on April 24, 2025. There were no case consultation notes documented in the record at the time of the inspection.
Client # 7 was admitted on January 27, 2025 and was discharged on May 12, 2025. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure that all Case Consultation notes are completed every 90 days and the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct 5 chart audits per month to verify completion. The Program Coordinator will send monthly reminders to staff. This will be reviewed during individual supervisions. This will begin on 8/15/25.
All staff will be provided with re-training on documentation requirements regarding Case Consultation notes. Training will occur during individual and group supervision. This will occur by 8/30/25.
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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 maintain a complete client record, which is to include documentation of follow-up information, in two of three applicable client records reviewed.
The facility policy and procedure manual states that follow-up activity will be completed within 7 days of discharge for all clients who successfully completed treatment.
Client # 4 was admitted on January 8, 2025 and was successfully discharged on April 24, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 5 was admitted on February 12, 2025 and was successfully discharged on March 4, 2025. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
4. In order to ensure that all follow up occurs 7 days post-discharge, the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct 5 chart audits per month to verify completion. The Program Coordinator will send monthly reminders to staff. This will be reviewed during individual supervisions. This will begin on 8/15/25. |