INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc dba Holcomb Behavioral Health System 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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven records reviewed.
Client #4 was admitted on July 3, 2025, and was discharged on November 10, 2025. The facility failed to document a release of information for the funding source until September 15, 2025; however, it was verified that billing began to occur July 3, 2025.
Client #5 was admitted on July 29, 2025, and was discharged on November 9, 2025. Facility staff communicated with the client ' s probation officer; however, there was no release of information documented prior to the disclosure.
Client #6 was admitted on September 16, 2025, and was discharged on January 6, 2026. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will develop an updated guide outlining when ROIs are required and listing common providers/entities. This will include instructions for accurate and timely completion.
The Program Director will complete 5 chart audits per month to verify timely and accurate ROI completion.
All staff will receive re training on ROI requirements during individual and group supervision. This includes when ROI is required, how to complete them correctly, and documentation expectations. This will occur by 6/22/26
Audit results will be reviewed monthly by the Program Director to ensure continued compliance and identify any additional training needs.
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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 the review of client records and the project ' s policies and procedures manual, the project failed to document a complete client record on an individual that included a follow-up contact note within seven days of discharge, per facility policy, in two of four applicable records reviewed.
Client #5 was admitted on July 29, 2025, and was discharged on November 9, 2025. There was no follow-up contact documented in the client record.
Client #6 was admitted on September 16, 2025, and was discharged on January 6, 2026. There was no follow-up contact documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will retrain all staff on updated guidelines requiring completion of 7 day post discharge follow up contacts for every discharged client. This will occur by 6/22/26 during individual and group supervisions.
During weekly supervisions, the Program Director will review all pending discharges with staff and ensure the 7 day follow up contact is scheduled in the electronic health record.
The Program Director will complete weekly chart audits to verify timely completion and documentation of all required 7 day follow up contacts. He will document completion in a tracking system.
Audit findings will be reviewed regularly to identify gaps and provide additional staff support or training as needed.
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