INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 7, 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:
|
Plan of Correction
|
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.
|
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.
Every 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.
|
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. Training plans for existing PA
employees will be redone
using the new form. This will be monitored by random monthly audits beginning 2.28.26 by compliance team. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
Based on a physical plant inspection, conducted at approximately 12:00 p.m., the facility failed to maintain a minimum of two exits on every floor, which are separated by a minimum distance of 15 feet.
At the time of the inspection, the facility is located on the third floor and was using a stairwell as one exit and a set of elevators as the second exit. However, during emergency fire evacuations and fire drills, elevators cannot be used as an exit. Since elevators cannot be used as an exit from the facility, the stairwell was the only option to exit the facility.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Compliance Team and Facility Leadership will collaborate with Building Management to identify, implement, and document the necessary corrective actions required to meet the cited regulatory requirement. An action plan has been finalized as of date of survey and will be finalized by 7.7.26. All required modifications and/or corrective measures will be completed within the six (6) month timeframe granted by the Department. Executive Director and Staff will continue to use current evacuation and fire safety procedures to respond to any fire safety issues until action item is completed. The Compliance Team will conduct bi-weekly progress reviews with Facility Leadership and Building Management to ensure the project remains on schedule. Documentation of meetings, action steps, and completion milestones will be maintained. Upon completion, a final compliance verification review will be conducted to ensure the requirement has been fully met and sustained. |
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.
|
Observations
Based on a review of the facility's August 2025 through November 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 documentation provided indicating fire drills were conducted during the months of June 2025 and July 2025.
This finding was reviewed with facility staff during the licensing process.
|
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.
|
Observations
Based on a review of the August 2025 through November 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.
At the time of the inspection, the facility did not include and was unable to provide documentation of the number of persons in the facility at the time of the fire drill conducted during each of the months of August 2025 through November 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The existing Safety Drill Log
Form has been revised as of 1.20.26 by Regional Director and Compliance. Staff conducting fire drill 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 to ensure form is completed correctly with required fields. 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 form requirements. |
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.
|
Observations
Based on review of the facility's August 2025 through November 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 logs for the fire drills conducted during the months of August 2025 through November 2025 did not include documentation of whether a fire alarm or smoke detector was set off during the drills.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director completed request for exemption form for regulation 705.28.d.7 and it was submitted to the department on 1/30/2026. Executive reached out to follow up on the status of the submitted exemption on 2.17.26. Executive Director will complete drills with alternative means to announce the drill until status updated. Fire safety will be monitored monthly by Executive Director and Compliance Dept. during monthly Health and Safety inspections to ensure fire drills are completed per policy. |
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.
|
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 four of eight client records reviewed.
Client #2 was admitted to the outpatient activity on October 10, 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 November 11, 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 #5 was admitted to the outpatient activity on November 19, 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 #6 was admitted to the outpatient activity on October 27, 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.
|
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 1.7.26.
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. |
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.
|
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 six applicable client records reviewed.
Client #1 was admitted to the outpatient activity on October 6, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 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 #2 was admitted to the outpatient activity on October 10, 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 frequency treatment and rehabilitation services being provided to the client.
Client #4 was admitted to the outpatient activity on November 6, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 11, 2025; however, the plan did not include documentation of the frequency treatment and rehabilitation services being provided to the client.
Client #6 was admitted to the outpatient activity on October 27, 2025 and was discharged on December 29, 2025. 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.
This finding was reviewed with facility staff during the licensing process.
|
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. |