INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Kolmac Outpatient Recovery 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 a review of client records, the facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in three of ten client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on March 23, 2026 and was discharged on April 7, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client # 7 was admitted to the outpatient activity on January 6, 2026 and was discharged January 19, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client # 10 was admitted to the outpatient activity on October 14, 2025 and was discharged on July 3, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the January 5, 2026 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with
signing the Treatment,
Payment, and Health
Operations (TPO) Consent,
our Patient Engagement team
will have the patient sign this
document at the same time
they sign the Consent for
Treatment, ensuring both are
signed prior to the patient
receiving any services.
This new process will be
implemented by the Vice
President if Operations by
8/24/2026.
Compliance to the new
procedure will be monitored
by monthly chart audits
conducted by the Executive
Director and/or clinical
team. |
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 client records, the facility failed to ensure a copy of a consent to release information form was offered to the client in one of ten client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on June 23, 2026 and was discharged on June 29, 2026. A release of information form to a funding source was signed and dated by the client on June 22, 2026; however, there was no documentation in the record indicating a copy of the release form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The compliance team will
work with our IT team to add
a check box to the TPO
consent to indicate that a copy
of the completed release was
offered to the patient.
Compliance with the updated
form will be monitored by
monthly chart audits
conducted by the Executive
Director and/or clinical team.
Request to update the form
submitted to IT team on
8/12/2026 by Operations Coordinator. |
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 and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of case consultation notes, in five of five applicable records reviewed.
The facility policy and procedure manual indicated that case consultation notes will be completed at least quarterly.
Client # 5 was admitted to the outpatient activity on November 5, 2025 and was discharged on July 2, 2026. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 6 was admitted to the outpatient activity on February 26, 2026 and was discharged on July 2, 2026. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 8 was admitted to the outpatient activity on January 12, 2026 and was discharged on April 13, 2026. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 9 was admitted to the outpatient activity on March 10, 2026 and was discharged on July 7, 2026. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 10 was admitted to the outpatient activity on October 14, 2025 and was discharged on July 3, 2026. There was no documentation of case consultation notes 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
The compliance team will work
with our IT to add a case
consultation note into our EMR
to be completed by clinicians at
either the time patient
transitions level of care or at
patient's 90 days, whichever
comes first.
The compliance team will work
with the IT team to implement
this change by 8/31/2026.
Compliance with this new form
will be monitored by monthly
chart audits conducted by the
Executive Director and/or
clinical team. |