INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 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 Behavioral Health Systems 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 fire drill logs from December 2024 through July 2025, the facility failed to conduct an unannounced fire drill during the months of January 2025, February 2025, April 2025 and May 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Environment of Care Representative will conduct Fire Drills monthly and during varied times so that staff on all shifts receive Fire Drill training.
This will be reviewed monthly by the Program Director to ensure completion. |