INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 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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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 a review of personnel records, the facility failed to ensure a written individual training plan was developed for each employee annually, with input from both the employee and the supervisor, in three of three personnel records reviewed.
Each individual training plan provided and reviewed was a self-assessment and was completed by the employee; however, there was no documentation in the personnel records indicating any of the training plans were completed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Dept will work
with IT Dept to update the
Training Plan form in our EMR,
Credible, to include
a section for supervisor
feedback. This system will allow
for both employee and
supervisor feedback to be
documented on the same form.
Executive Director and Compliance Dept will create Standard Operating Procedure that will outline the procedure for
completing the training plan
and the Executive Director will be retrained by 2.28.26 and train any additional supervisors who will be completing the training plans moving forward. Training plan form revision will be completed by 2.28.26 and any completed training plans following this date will be required to use updated form. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an administrative review, the facility failed to ensure a sufficient number of CPR-certified staff persons were on-site during the project's hours of operation.
The facility provided documentation showing three employees who work on-site, had first aid training and two employees had current CPR certification. One of the CPR-certified employees only works on-site at the facility on Mondays. As of the date of the inspection, there is only one CPR-certified employee on-site during the facility's Tuesday through Friday 9:00 AM to 9:00 PM posted hours of operation. One employee is not sufficient to provide CPR certification coverage during these posted hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director for the
facility has completed CPR/
AED training as of 1.22.26. The site now
has a sufficient number of
trained staff to ensure
coverage. Compliance Dept will support HR Dept with completing quarterly audits of HR files to ensure that proper requirements are met on continual basis. |
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 November 2025 and December 2025 fire drill log, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided indicating fire drills were conducted during the months of May 2025 through September 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been retrained on
fire drill requirements as of 1.20.26. Fire drills will continue to be conducted per policy. Executive Director will complete monthly Health and Safety Inspections that include fire safety. Compliance Dept will continue to complete monthly health and safety audits to ensure site is complying with requirements. Leadership is now aware of fire safety requirements regardless of unoccupied space. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the November 2025 through December 2025 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The facility failed to include documentation of the number of persons in the facility at the time of the fire drill conducted during the month of December 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The existing Safety Drill Log
Form has been revised as of 1.31.26 to
include a field to document the
number of participants who
completed the drill. Executive Director has been retrained as of 1.31.26 and will provide ongoing training as needed to new staff. The completion of these forms will be monitored monthly during Health and Safety Inspections that will be completed by Executive Director. This will be audited monthly by Compliance Dept for completion. |
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 review of the facility's November 2025 through December 2025 fire drill logs, the facility failed to set off the fire alarm or a smoke detector during each fire drill.
At the time of the inspection, the fire drill logs for the months of November 2025, and December 2025 did not include documentation of the failed setting off the fire alarm or smoke detector during the drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director completed request for exemption form for
regulation 705.28.d.7 and it was
submitted to the department
on 1/27/2026. This has been accepted as of 2.4.26. Executive Director will complete drills with alternative means to announce the drill as of 2.4.26. |
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 from the client for the disclosure of information contained in the client record in five of five applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 5, 2025 and was active at the time of the inspection. 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 #3 was admitted to the outpatient activity on October 14, 2025 and was active at the time of the inspection. 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 #4 was admitted to the outpatient activity on October 17, 2025 and was discharged on November 20, 2025. 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 #5 was admitted to the outpatient activity on November 25, 2025 and was discharged on January 2, 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 #6 was admitted to the partial hospitalization activity on November 4, 2025 and was discharged on December 29, 2025. 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 finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Compliance Dept ensured that this ROI specific to PA Funding
Source is active and working in patient portal for all
patients to sign as of 1.31.26.
Executive Director will complete monthly charts for active patients. Compliance Dept will monitor chart compliance during monthly reviews of patient charts, minimum of two charts per program.
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709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short- and long-term goals for treatment as formulated by both staff and client on the individual treatment and rehabilitation plan in one of one applicable client record reviewed.
Client #6 was admitted into the partial hospitalization activity on November 4, 2025 and was discharged on December 29, 2025. The individual treatment and rehabilitation plan was completed on November 11, 2025; however, the plan did not include documentation of short- and long-term goals for treatment as formulated by both staff and client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
IT Dept and Executive Director confirmed issue was resolved regarding auditor access to Credible and now allows for the
full view of the treatment plan to
include short and long term
goals. The permissions for the
auditor view in our EMR have
been updated to allow for this
information to be visible as of 1.31.26. Leadership is ensuring that proper access is given prior to future audits. As a proactive measure, all staff has been retrained on treatment plan expectations and requirements as of 1.31.26. Executive Director will complete monthly chart audits to monitor compliance and Compliance Department will monitor monthly chart submissions minimum of two charts per program for visibility. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment on the individual treatment and rehabilitation plan in one of one applicable client record reviewed.
Client #6 was admitted into the partial hospitalization activity on November 4, 2025 and was discharged on December 29, 2025. The individual treatment and rehabilitation plan was completed on November 11, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services being provided to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will
train staff on adding the
frequency in the intervention
section of the treatment plans.
This is a short-term solution
until the form in our EMR
system can be updated.
The Compliance Team will
work our IT Team to update
the treatment plan form to
include a specific area to
indicate the frequency of
treatment and rehabilitation
services. Once completed,
staff will be retrained on the
form. Charts will be audited
weekly to ensure compliance. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed types of support services on the individual treatment and rehabilitation plan in one of one applicable client record reviewed.
Client #6 was admitted to the partial hospitalization activity on November 4, 2025 and was discharged on December 29, 2025. The individual treatment and rehabilitation plan was completed on November 11, 2025; however, the plan did not include documentation of the proposed types of support services.
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
update the treatment plan form
to include a check box for
supportive services and options
to indicate which supportive
services the patient is utilizing
(AA, NA, SMART Recovery) as of 2.28.26.Executive Director will retrain staff by 2.28.26 once form is completed and complete monthly chart audits. Compliance Dept will monitor compliance monthly minimum of two charts per program.
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the short- and long-term goals for treatment as formulated by both staff and client on the individual treatment and rehabilitation plan in three of four applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 5, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 12, 2025; however, the plan did not include documentation of the short- and long-term goals for treatment as formulated by both staff and client.
Client #4 was admitted to the outpatient activity on October 17, 2025 and was discharged on November 20, 2025. The individual treatment and rehabilitation plan was completed on October 21, 2025; however, the plan did not include documentation of the short- and long-term goals for treatment as formulated by both staff and client.
Client #5 was admitted to the outpatient activity on November 25, 2025 and was discharged on January 2, 2026. The individual treatment and rehabilitation plan was completed on November 28, 2025; however, the plan did not include documentation of the short- and long-term goals for treatment as formulated by both staff and client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
IT Dept and Executive Director confirmed issue was resolved regarding auditor access to Credible and now allows for the full view of the treatment plan to
include short and long-term goals. The permissions for the auditor view in our EMR have been updated to allow for this information to be visible as of 1.20.26. Leadership is ensuring that proper access is given prior to future audits. As a proactive measure, all staff has been retrained on treatment plan expectations and requirements as of 1.20.26. Executive Director will complete monthly chart audits to monitor compliance and Compliance Department will monitor monthly chart submissions minimum of two charts per program for visibility. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment on the individual treatment and rehabilitation plan in four of four applicable client records reviewed.
Client #1 was admitted to the outpatient activity on November 5, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 12, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services being provided to the client.
Client #3 was admitted to the outpatient activity on October 14, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 22, 2025; however, the plan did not include documentation of the type of treatment and rehabilitation services being provided to the client.
Client #4 was admitted to the outpatient activity on October 17, 2025 and was discharged on November 20, 2025. The individual treatment and rehabilitation plan was completed on October 21, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services being provided to the client.
Client #5 was admitted to the outpatient activity on November 25, 2025 and was discharged on January 2, 2026. The individual treatment and rehabilitation plan was completed on November 28, 2025; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services being provided to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will
train staff on adding the
frequency in the intervention
section of the treatment plans.
This is a short-term solution
until the form in our EMR
system can be updated.
The Compliance Team will
work our IT Team to update
the treatment plan form to
include a specific area to
indicate the frequency of
treatment and rehabilitation
services. Once completed, staff
will be retrained on the form.
Charts will be audited weekly to ensure compliance. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed types of support services on the individual treatment and rehabilitation plan in three of four applicable client records reviewed.
Client #3 was admitted to the outpatient activity on October 14, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 22, 2025; however, the plan did not include documentation of the proposed types of support services.
Client #4 was admitted to the outpatient activity on October 17, 2025 and was discharged on November 20, 2025. The individual treatment and rehabilitation plan was completed on October 21, 2025; however, the plan did not include documentation of the proposed types of support services.
Client #5 was admitted to the outpatient activity on November 25, 2025 and was discharged on January 2, 2026. The individual treatment and rehabilitation plan was completed on November 28, 2025; however, the plan did not include documentation of the proposed types of support services.
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
update the treatment plan
form to include a check box
for supportive services and
options to indicate which
supportive services the patient
is utilizing
(AA, NA, SMART Recovery) by 2.28.26.
Once completed, Executive Director will train staff on the additional requirement on the form. The Executive Director will complete monthly chart audits and Compliance Dept will monitor chart submission and compliance a minimum of two charts per program monthly. |