INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 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 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(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 a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually, during the facility's January 1, 2024 through December 31, 2024 training year, in one of one applicable personnel records reviewed.
Employee # 5 was hired as a counselor on August 26, 2019. The personnel record included documentation of 14 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Professional Development Plan will be developed and updated annually for all counselors by Clinical Coordinator. The plan will include 25 hours of DDAP approved trainings.
A staff training tracking form will be utilized by 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.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's May 2024 through February 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no monthly fire drill conducted and documented during the month of July 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director will review the fire drill schedule 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 each month.
The status of the fire drill report (scheduled date, completion date, report submitted) will be reviewed during weekly supervisions. In the event that the CSS Coordinator is not available to conduct the fire drill, the Regional Director will be responsible for ensuring the fire drill is completed. |
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 three of four applicable client records reviewed.
Client # 1 was admitted on May 31, 2024 and was still active at the time of the inspection. The individual treatment plan was completed on June 14, 2024 and the first update was due no later than August 14, 2024; however, the update was not completed until October 11, 2024.
Client # 5 was admitted on December 28, 2022 and was discharged on February 14, 2025. A treatment plan update was completed on July 19, 2024 and the next update was due no later than September 19, 2024; however, the update was not completed until October 1, 2024. Additionally, a treatment plan update was completed on October 1, 2024 and the next update was due no later than December 1, 2024; however, the update was not completed until December 6, 2024.
Client # 6 was admitted on January 5, 2023 and was discharged on December 6, 2024. A treatment plan update was completed on April 17, 2024 and the next update was due no later than June 17, 2024; however, the update was not completed until July 17, 2024.
This is a repeat citation from the May 16, 2023 and April 4, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Coordinator will utilize a treatment plan tracking tool to monitor due dates, and will review upcoming treatment plans with counselors during monthly 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. If ongoing non-compliance is identified, supervisions will be utilized for reminders. If non-compliance continues, progressive discipline will follow. |
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.
Plans of correction for failing to ensure each client's treatment and rehabilitation plans are updated at least every 60 days were submitted and approved by the Department from the May 16, 2023 and April 4, 2024 annual licensing inspections. Failing to ensure treatment plans are updated at least every 60 days was again found to be a deficiency in the March 27, 2025 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director will conduct a monthly review of all clinical plans of correction (treatment plan dates, staff training), with the Clinical Coordinator and a monthly review of the facility plan of correction (fire drills) with the Clinical Support Specialist Coordinator to ensure compliance. A plan of action will be developed for any issues noted, with serious concerns elevated to the Director of Operations or Human Resources as appropriate for further action. |