INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 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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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 April 2024 through December 2024 fire drill logs, the facility failed to ensure their written fire drill logs included the documentation of the amount of time it took for evacuation. Every fire drill log reviewed was missing the documentation of the amount of time it took for evacuation.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility did not monitor if exit time from the building for fire drills were being accurately recorded on fire drill logs. To ensure compliance with fire safety, the EOC representative running the fire drills will be responsible for ensuring drills are timed. The Regional Director will work with the EOC representatives to ensure compliance and will review the fire drills monthly. The monthly report for fire drills will then be reviewed in the Facility's quality management meeting for 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 review and update treatment and rehabilitation plans at least every sixty days in three of seven client records reviewed. Client # 1 was admitted on May 13, 2024 and was still active at the time of the inspection. A treatment plan update was completed on August 19, 2024 and the next update was due no later than October 19, 2024; however, the update was not completed until November 19, 2024. Client #2 was admitted on September 23, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 4, 2024 and the next update was due no later than February 4, 2025; however, the update was not completed until February 14, 2025. Client # 3 was admitted on July 16, 2024 and was still active at the time of the inspection. A treatment plan update was completed on December 4, 2024 and the next update was due no later than February 4, 2025; however, the update was not completed until February 14, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Coordinator will maintain a tracking mechanism to monitor and ensure compliance with timeliness of treatment plan updates. The Clinical Coordinator will track on a weekly basis initial and master treatment plan updates that are needed. Treatment plan due dates for each client on their caseload will be emailed to all clinical staff on a weekly basis. For any outstanding treatment plans, the Clinical Coordinator will follow-up with staff to determine whether the client is pending discharge and requires discharge paperwork to be completed. The Clinical Manager will review treatment plan timeliness on a monthly basis to monitor compliance. In addition, the Clinical Coordinator will complete a refresher training on completing timely discharges with all clinical staff. The Clinical Manager will also track and monitor timeliness of discharges to ensure compliance within the agency's policies. |