INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 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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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 July 2025 through June 2026 fire drill logs, the facility failed to ensure unannounced fire drills were conducted at least once a month.
At the time of the inspection, there were no fire drills conducted during the months of July 2025, August 2025, October 2025, November 2025 and December 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be conducted by the Executive Director monthly in accordance with 705.28. The drills will be recorded on the updated drill log to include the number of individuals who participated in the drill.
Compliance will be monitored through monthly Health and Safety audits conducted by the Operations Coordinator and Director of Compliance.
New form and process already in place.
Failure to comply will result in disciplinary action. |
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 facility's July 2025 through June 2026 fire drill logs, the facility failed to document on their written fire drill record the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector is operative.
At the time of the inspection, the log for the fire drill conducted during the month of February 2026 was missing the number of persons in the facility at the time of inspection. Additionally, the logs for the fire drills conducted during the months of January 2026 through June 2026 were missing whether the fire alarm or smoke detector was operative during the fire drills.
This finding was 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.
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. |
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 a review of the facility's July 2025 through June 2026 fire drill logs, the facility failed to ensure a fire alarm or smoke detector was set off during each fire drill conducted during the months of January 2026 through June 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Coordinator
submitted an exception
request on 7/23/2026 to allow
for an alternate method of
announcing drills. The
exception was approved on
7/23/2026. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project's performance.
At the time of the inspection, the Department representative requested from the facility a list of their active and discharged clients for the period covering July 17, 2025 to the date of the inspection. The facility reported no current, active clients; however, there were three discharged clients, which were reviewed as active during the previous annual licensing renewal inspection. Facility staff were only able to produce the client records for two of the three discharged clients and could not locate the third discharged client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, staff will be educated on maintaining notes from the previous audits to ensure patients records can be retrieved efficiently.
Training will be provided by the Regional Director of Operations. All staff trained will sign an attestation confirming their participation in and understanding of the training. |