INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. The men's bathroom hot water was recorded at 124 degrees.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The hot water heater was adjusted to 120 temperature. The Outpatient Director will monitor temperature for compliance. The Maintenance Manager will periodically check/adjust the temperature as needed. |
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 March, 2025 through March, 2026 fire drill logs during the inspection, the facility failed to document the exit route used during the fire drill on the May, 30, 2025 fire drill log.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill log was updated and
the policy regarding monthly fire drills was reviewed with the Outpatient Program Director. All requirements such as documentation of time, exits and methods were reviewed. The Operations Director will complete random audits of facility fire drill logs to ensure 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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #10 was admitted on September 17, 2025 and was still active at the time of the inspection. A treatment plan update was completed on October 22, 2025 and an update was due no later than December 22, 2025; however, it was not completed until December 29, 2025. Additionally, the next update was due no later than March 1, 2026; however, it was not completed until March 3, 2026.
Client #12 was admitted on September 11, 2025 and was discharged on January 8, 2026. A treatment plan update was completed on October 27, 2025 and an update was due no later than December 27, 2025; however, none was completed.
Client #13 was admitted on August 1, 2025 and was discharged on January 12, 2026. A comprehensive treatment plan was completed on August 12, 2025 and the next update was due no later than October 12, 2025; however, it was not completed until November 17, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 25, 2025 licensing inspection.
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Plan of Correction
Clinical staff will receive re-training by Director of Outpatient Programs on Colonial House policy/DDAP regulations associated with treatment plan review requirements and time frames. Monthly chart audits will be conducted by Director of Outpatients Programs to ensure compliance. |