INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 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-Philadelphia 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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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 January 2026 through June 2026 fire drill logs, the facility failed to maintain a written fire drill record, which is to include documenting the exit route used during the drill and the number of persons in the facility at the time of the drill.
At the time of the inspection, there was no documentation on the fire drill log indicating the number of persons in the facility at the time of the fire drill on the fire drill record conducted during each of the months of April 2026 through June 2026. Additionally, there was no documentation on the fire drill record indicating which exit route was used during the fire drill conducted during the month of April 2026.
This is a repeat citation from the January 7, 2026 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new drill log form has been
developed to include the
number of individuals who
participate in the drill and the
route used.
The Executive Director will
complete monthly fire drills in
accordance with 705.28.
Compliance will be monitored
through monthly Health and
Safety audits conducted by the
Operations Coordinator and
Director of Compliance.
Failure to comply will result in
disciplinary action. |
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 and rehabilitation services on the individual treatment and rehabilitation plan in five of five applicable client records reviewed.
Client # 2 was admitted into the partial hospitalization activity on February 2, 2026 and was discharged on February 27, 2026. The individual treatment plan was completed on February 11, 2026 and did not include documentation of the type and frequency of treatment services the client was to receive.
Client # 3 was admitted into the partial hospitalization activity on May 5, 2026 and was discharged on June 1, 2026. The individual treatment plan was completed on May 6, 2026 and did not include documentation of the type and frequency of treatment services the client was to receive.
Client # 4 was admitted to the partial hospitalization activity on June 1, 2026 and was discharged on July 17, 2026. The individual treatment plan was completed on June 19, 2026 and did not include documentation of the type and frequency of treatment services the client was to receive.
Client # 5 was admitted to the partial hospitalization activity on April 7, 2026 and was discharged on July 15, 2026. The individual treatment plan and subsequent treatment plan updates dated June 17, 2026 and July 8, 2026 did not include documentation of the type and frequency of treatment services the client was to receive.
Client # 6 was admitted to the partial hospitalization activity on February 3, 2026 and was discharged on July 21, 2026. The individual treatment plan was completed on February 11, 2026 and did not include documentation of the type and frequency of treatment services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will
provide a refresher training to
staff to review the
requirements for type and
frequency of services to be
indicated in the treatment
plan.
All staff trained will sign an
attestation confirming their
participation in and
understanding of the training.
The Executive Director will
perform monthly chart audits
to ensure compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in one of two applicable client records reviewed.
Client #5 was admitted to the partial hospitalization activity on February 3, 2026 and was discharged on July 21, 2026. A treatment plan update was completed on June 1 2026 and the next update was due no later than July 1, 2026; however, the update was not completed until July 6, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will
provide a refresher training to
staff to review the
requirement to update the
treatment plan at least every
30 days.
All staff trained will sign an
attestation confirming their
participation in and
understanding of the training.
The Executive Director will
perform monthly chart audits
to ensure compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling on a regular and scheduled basis, specifically individual counseling at least twice weekly, in two of six applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on June 29, 2026 and was active at the time of inspection. Individual counseling was to be provided to the client at least twice weekly; however, there were no individual counseling sessions documented since the client was admitted.
Client # 4 was admitted to the partial hospitalization activity on June 1, 2026 and was discharged on July 17, 2026. Individual counseling was to be provided at least twice weekly; however, there were no individual counseling sessions documented from July 6, 2026 until the date of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will
provide a refresher training to
staff to review the requirement
to provide individual
counseling at least twice
weekly.
All staff trained will sign an
attestation confirming their
participation in and
understanding of the training.
The Executive Director will
perform monthly chart audits
to ensure compliance. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) 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 the documentation of case consultation notes, in two of two applicable client records reviewed.
The facility policy and procedure manual indicated case consultation notes will be completed at least quarterly for all clients.
Client # 5 was admitted to the partial hospitalization activity on April 7, 2026 and was discharged on July 15, 2026. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 6 was admitted to the partial hospitalization activity on February 3, 2026 and was discharged on July 21, 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 team 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. |
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 and rehabilitation services on the individual treatment and rehabilitation plan in one of two applicable client records reviewed.
Client # 13 was admitted to the outpatient activity on May 21, 2026 and was discharged on June 30, 2026. The individual treatment and rehabilitation plan was completed on June 5, 2026 and did not include documentation of the type and frequency of treatment services the client was to receive.
This is a repeat citation from the January 7, 2026 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will
provide a refresher training to
staff to review the
requirements for type and
frequency of services to be
indicated in the treatment
plan.
All staff trained will sign an
attestation confirming their
participation in and
understanding of the training.
The Executive Director will
perform monthly chart audits
to ensure compliance. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of three applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on January 29, 2026 and was active at the time of inspection. A treatment plan update was completed on March 9, 2026 and the next update was due no later than May 9, 2026; however, the update was not completed at the time of the inspection.
Client # 9 was admitted to the outpatient activity on February 2, 2026 and was active at the time of inspection. A treatment plan update was completed on March 13, 2026 and the next update was due no later than May 13, 2026; however, the update was not completed until July 17, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will
provide a refresher training to
staff to review the
requirement to update the
treatment plan at least every
60 days.
All staff trained will sign an
attestation confirming their
participation in and
understanding of the training.
The Executive Director will
perform monthly chart audits
to ensure compliance.
The patient's chart was updated to reflect attempts to reengage patient in treatment and complete treatment plan. Outreach notes documented on 6/29/2026 and 8/19/2026 show that patient is pausing services due to financial reasons. The patient was discharged on 9/1/2026. |
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 two of two applicable records reviewed.
The facility policy and procedure manual indicated case consultation notes will be completed at least quarterly for all clients.
Client # 8 was admitted to the outpatient activity on January 29, 2026 and was active at the time of inspection. 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 February 2, 2026 and was active at the time of inspection. 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 team 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. |