INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2025 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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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.
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Observations
Based on a review of personnel records, the facility failed to develop an annual, written individual training plan for each employee,with input from both the employee and the supervisor, in two of two applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on May 19, 2025. The individual training plan was developed and signed by the employee on July 15, 2025; however, there was no documentation, in the personnel record, indicating the plan was developed with input from the supervisor.
Employee # 2 was hired as the clinical supervisor on August 14, 2024. The individual training plan was developed and signed by the employee on January 29, 2025; however, there was no documentation, in the personnel record, indicating the plan was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance will work with the Manager of
Organizational Training to create a section in the individual training plan for the supervisor to add input. Training plans will be updated and reviewed annually in Q1.
Existing training plans will be updated by 9/30/2025. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon staff employment in one of one applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on May 19, 2025. There was documentation in the personnel record indicating the fire extinguisher training was not completed until July 16, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire extinguisher training has been added
to New Hire Orientation. Staff will
receive training during their first week of New Hire Orientation by completing a training module in our learning management system. Training reports from our learning management system will be reviewed by weekly by the Compliance Manager to ensure all new hires have completed the required training. The Compliance Manager will report any incomplete trainings to the Executive Director to follow up with employees. The Compliance Team and Executive Director are responsible for the implementation of all corrective actions. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in one of one applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on May 19, 2025. There was documentation in the personnel record indicating the training to perform assigned tasks during emergencies was not completed until July 16, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire safety training has been added
to New Hire Orientation. Staff will
receive training during their first week
of New Hire Orientation. Compliance, Executive Director and the Manager of Organizational Training are responsible for the implementation and monitoring of training completion. |
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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 7 was admitted on January 23, 2024 and was discharged on April 1, 2025. There was evidence 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 any of the disclosures.
This is a repeat citation from the August 17, 2023 and July 9, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac has updated its patient onboarding
workflow to include 3 points
of contact to ensure patients are
completing all ROIs correctly.
Our Patient Engagement Team is
reaching out to patients via phone/text
and are staying on phone while patient
fills out forms in our patient portal.
Prior to clinical evaluation, the Patient
Engagement Team is checking to
ensure forms are completed in patient
portal.
Our Patient Access Specialists are
also checking patient portal
documentation to ensure nothing is
missed.
The Patient Access Director will
review all charts to ensure the forms
are completed accurately. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a release of information form in one of seven client records reviewed.
Client # 1 was admitted on March 10, 2025 and was still active at the time of inspection. The release of information form to the funding source was signed by the client on March 18, 2025; however, the specific information to be disclosed was not included on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Site Supervisor will train all
clinicians and admin staff on how to
properly complete a consent.
Consents will be audited weekly by
the Patient Access Director to
ensure the specific information to be
disclosed is clearly identified.
ROIs for the patients identified will be reviewed and updated by 9/30/2025. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in six of seven applicable client records reviewed.
The facility policy and procedure manual states the individual treatment and rehabilitation plan is to be completed within five days of completing the biopsychosocial assessment.
Client # 1 was admitted on March 10, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than March 22, 2025; however, the plan was not completed until March 27, 2025.
Client # 2 was admitted on March 7, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than March 11, 2025; however, the plan was not completed until March 19, 2025.
Client # 3 was admitted on February 3, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than March 22, 2025; however, the plan was not completed until March 27, 2025.
Client # 4 was admitted on November 11, 2024 and was discharged on February 10, 2025. The individual treatment and rehabilitation plan was due to be completed no later than November 17, 2024; however, the plan was not completed until November 26, 2024.
Client # 6 was admitted on March 13, 2025 and was discharged on May 9, 2025. The individual treatment and rehabilitation plan was due to be completed no later than March 24, 2025; however, the plan was not completed until March 27, 2025.
Client # 7 was admitted on January 23, 2025 and was discharged on April 1, 2025. The individual treatment and rehabilitation plan was due to be completed no later than January 28, 2025; however, the plan was not completed until February 20, 2025.
This is a repeat citation from the July 9, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff members responsible for treatment plans were put on performance improvement plan toaddress late treatment plans. The
Executive Director will monitor daily
case management report to ensure
treatment plans are completed within
5 days of BPS.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of three applicable records reviewed.
Client # 6 was admitted on March 13, 2025 and was discharged on May 9, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 7 was admitted on January 23, 2025 and was discharged on April 1, 2025. There was no follow-up information documented in the record as of the date of the inspection.
This is a repeat citation from the July 9, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Admissions Director will review discharge workflow with Patient Engagement team for follow up calls. The Admissions Director will conduct training on how to complete a follow up call and documentation in the charts. The Admissions Director will audit discharges for follow up calls every 30 days. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to obtain an informed and voluntary consent to release information form prior to the disclosure of information were submitted and approved by the Department for the August 17, 2023 and July 9, 2024 annual licensing inspections. Failing to obtain an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency in the July 17, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kolmac has recently hired a new
Executive Director to oversee the Yardley
office. The Executive Director and
Compliance Team will work together to
ensure implementation of the corrective
action plan, which will include detailed
documentation audits and monthly
review meetings. Any deficiencies
identified will be resolved within 3
business days. |