INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 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. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the project failed to document a written initial individual training plan for each employee within thirty days of their hire date, that is appropriate to that employee's skill level with input from both the employee and the supervisor in one out of three records reviewed.
Employee #1 was hired as a project director on January 20, 2026 and was currently in that position at the time of the inspection. An individual training plan was to be documented in the personnel record no later than February 20, 2026; however, an individual training plan was not documented in the personnel record until March 30, 2026.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A Professional Development Plan will be developed within 30 days of hire, and updated annually by the Clinical Coordinator for all counselors and by the Regional Director for the Clinical Coordinator prior to 1/1/27. An on-boarding tracker will be utilized to ensure all new hires receive a Development Plan within 30 days of hire, and an ongoing training tracker will be utilized to ensure all staff receive an updated plan annually with input from both the employee and supervisor.
The Clinical Coordinator and Regional Director will review the staff Development Plan tracker monthly during supervision. If ongoing non-compliance is identified, supervisions will be utilized for reminders. If non-compliance continues, progressive discipline will follow.
The Quality Management Committee who is comprised of the COO, Clinical Director, Director of Operations, Regional Director, and Director of Quality and Compliance, will monitor this Corrective Action Plan on a monthly basis to ensure compliance with this plan of correction. If areas of noncompliance arise, QM Committee will involve HR or Quality/Compliance to implement further corrective action.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records, the project failed to ensure that a counselor completed at least 25 clock hours of training annually in one of one personnel record reviewed.
Employee #3 was hired as a counselor on August 26, 2019 and was currently in that position at the time of the inspection. Employee #3 only completed 16.5 training hours for the 2025 training year.
This is a repeat citation from the March 27, 2025, annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Identified barriers to implementing prior POC: Coordinator position was vacant for second half of 2025, and the only SUD counselor was out on leave at the end of the year.
Hired a new Clinical Coordinator in January 2026 and trained them on the Staff Training tracking tool. Training hours will be divided throughout the year with a target deadline of November 2026 in the event the employee/s are not able to complete trainings before 12/31/26 Expectations were discussed with the counselor and included on disciplinary action; the Clinical Coordinator will review during weekly supervisions for ongoing compliance.
A Professional Development Plan was developed, and will be updated annually prior to 1/1/27 for all counselors by the Clinical Coordinator. The plan will include 25 hours of DDAP approved trainings.
A Staff Training tracking form will be utilized by the Clinical Coordinator to ensure trainings are completed, and certificates will be kept on file with their HR records. The Clinical Coordinator will review due dates monthly with the counselor during individual supervision to ensure ongoing progress is achieved.
The Clinical Coordinator and Regional Director will review the Staff Development Plan tracker monthly during supervision. If ongoing non-compliance is identified, supervisions will be utilized for reminders. If non-compliance continues, progressive discipline will follow.
Our Quality Management Committee who is comprised of the COO, Clinical Director, Director of Operations, Regional Director, and Director of Quality and Compliance, will monitor this Corrective Action Plan on a monthly basis to ensure compliance with this plan of correction. If areas of noncompliance arise, QM Committee will involve HR or Quality/Compliance to implement further corrective action.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on April 2, 2026, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
When tested, the hot water in a staff bathroom was 142 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities' Department inspected the water temperature and adjusted the settings to under 120F on 4/6/26.
The Clinical Support Specialist Coordinator (CSS Coordinator) will test the water quarterly, document the temperature reading on the quarterly facility inspection report, and notify the Facilities' Department and Regional Director of any issues by the close of business that day. The Regional Director will also review the quarterly inspection report every quarter to ensure any water temperature concerns were addressed.
The Quality Management Committee who is comprised of the COO, Clinical Director, Director of Operations, Regional Director, and Director of Quality and Compliance, will monitor this Corrective Action Plan on a monthly basis to ensure compliance with this plan of correction. If areas of noncompliance arise, QM Committee will involve HR or Quality/Compliance to implement further corrective action.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill log from April 2025 through March 2026, the facility failed to prepare alternate exit routes to be used during fire drills.
The same exit was documented during each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director will review the fire drill schedule and exit door plans at the beginning of each month with the Clinical Support Specialist Coordinator (CSS Coordinator) who is responsible for conducting fire drills. The CSS Coordinator will email the completed fire drill report to the Regional Director. The status of the fire drill report will be reviewed during weekly supervision to ensure that alternate exits are included. In the event that the CSS Coordinator is not available, the Regional Director will ensure that the fire drill is completed.
The Quality Management Committee who is comprised of the COO, Clinical Director, Director of Operations, Regional Director, and Director of Quality and Compliance, will monitor this Corrective Action Plan on a monthly basis to ensure compliance with this plan of correction. If areas of noncompliance arise, QM Committee will involve HR or Quality/Compliance to implement further corrective action.
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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 the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of three applicable client records reviewed.
Client #4 was admitted on July 31, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on July 31, 2025, with the update due no later than September 31, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until October 9, 2025. Additionally, the next treatment and rehabilitation plan update was due no later than December 9, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record at the time of the inspection.
Client #5 was admitted on June 27, 2025 and was a current client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on July 18, 2025, with the next update due no later than September 18, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until October 17, 2025. Additionally, the next treatment and rehabilitation plan update was due no later than December 17, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until March 31, 2026.
Client #6 was admitted on June 4, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on May 31, 2025, with the update due no later than July 30, 2025; however, there was no updated treatment and rehabilitation plan documented in the client record until October 11, 2025.
This is a repeat citation from the May 16, 2023, April 4, 2024, and March 27, 2025, annual renewal licensing inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Identified barriers to implementing prior POC: Coordinator position was vacant for second half of 2025, and the only SUD counselor was out on leave at the end of the year.
Hired a new Clinical Coordinator in January 2026 and trained them on the Treatment Plan update timeline and the Treatment Plan tracking tool.
Expectations were discussed with the counselor and included on current disciplinary action; the Clinical Coordinator will review during weekly supervisions for ongoing compliance.
The program is actively recruiting additional counselors to prevent gaps in services if one counselor is unable to meet the plan's due dates due to absence.
The Clinical Coordinator is completing the ASAM training and will serve as a back-up counselor if the employee/s is not available to provide services and update Treatment Plans.
The Clinical Coordinator will utilize a treatment plan tracking tool to monitor due dates, and will review upcoming treatment plans with counselors during weekly supervision meetings to ensure plans are developed during evaluations, updated 30 days after admission, and every 60 days until discharge. A minimum of 2 monthly chart reviews will be conducted by the Clinical Coordinator to monitor compliance with the POC.
The Clinical Coordinator and Regional Director will review the staff development plan tracker monthly during supervision. If ongoing non-compliance is identified, supervisions will be utilized for reminders. If non-compliance continues, progressive discipline will follow.
Additionally, our Quality Management Committee who is comprised of the COO, Clinical Director, Director of Operations, Regional Director, and Director of Quality and Compliance, will monitor this Corrective Action Plan on a monthly basis to ensure compliance with this plan of correction. If areas of noncompliance arise, QM Committee will involve HR or Quality/Compliance to implement further corrective action.
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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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for reviewing and updating treatment and rehabilitation plans at least every 60 days was submitted and approved by the Department for the May 16, 2023, April 4, 2024, and March 27, 2025, annual renewal licensing inspections. Reviewing and updating treatment and rehabilitation plans at least every 60 days was again found to be a deficiency in the April 2, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Management Committee who is comprised of the COO, Clinical Director, Director of Operations, Regional Director, and Director of Quality and Compliance, will monitor this Corrective Action Plan on a monthly basis to ensure compliance with this plan of correction. If areas of noncompliance arise, QM Committee will involve HR or Quality/Compliance to implement further corrective action.
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