INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 14, 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:
|
Plan of Correction
|
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, there was a portable space heater located in the facility's storage closet.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Regional Director immediately removed the Portable Space Heater from the facility on 10/14/25.
The regional director will remind staff via email and during individual supervisions that portable space heaters are not allowed on the premises under any circumstances. This will occur by 11/17/25.
Program Director will conduct office walk through monthly after fire drills to ensure no space heaters are in the office. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
|
Observations
Based on a review of the February 2025 through September 2025 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
The facility's posted hours of operation are Monday to Thursday from 8:30AM to 9:00PM and Friday from 8:30AM to 5:00PM. The fire drill completed on Friday, July 11, 2025 was conducted at 5:02PM, which was outside the posted hours of operation and normal staffing conditions for a Friday.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Regional Director reviewed fire drill protocol with facility staff regarding the requirement to complete fire drills during office hours.
Regional director will review the log each month to ensure it is completed correctly and during the appropriate times. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan, during the intake and admission process, in six of seven client records reviewed.
The facility policy and procedure manual stated that the preliminary treatment and rehabilitation plan is to be completed on the date of admission.
Client # 1 was admitted on May 28, 2025 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than May 28, 2025; however, the plan was not completed until June 10, 2025.
Client # 2 was admitted on August 4, 2025 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than August 4, 2025; however, the plan was not completed until August 27, 2025.
Client # 4 was admitted on March 31, 2025 and was discharged on August 28, 2025. The preliminary treatment plan was due to be completed no later than March 31, 2025; however, the plan was not completed until May 1, 2025.
Client # 5 was admitted on April 1, 2025 and was discharged on June 25, 2025. The preliminary treatment plan was due to be completed no later than April 1, 2025; however, the plan was not completed until April 16, 2025.
Client # 6 was admitted on January 28, 2025 and was discharged on May 27, 2025. There was no preliminary treatment plan documented in the record at the time of the inspection.
Client # 7 was admitted on April 14, 2025 and was discharged on June 16, 2025. The preliminary treatment plan was due to be completed no later than April 14, 2025; however, the plan was not completed until April 21, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
2. In order to ensure that all Preliminary Treatment Plans are completed on time, the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct a chart audit to verify completion of the initial treatment plan when an intake is submitted for approval. This will be updated in the tracker.
All staff will be provided with re-training on documentation requirements regarding initial treatment planning and the goal of completing it during the intake. Training will occur during individual and group supervision. This will occur by 12/15/25.
|
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:
|
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 client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within thirty days of admission.
Client # 1 was admitted on May 28, 2025 and was still active at the time of the inspection. The individual treatment plan was due to be completed no later than June 28, 2025; however, the plan was not completed until July 16, 2025.
Client # 2 was admitted on August 4, 2025 and was still active at the time of the inspection. There was no individual treatment plan documented in the record at the time of the inspection.
Client # 4 was admitted on March 31, 2025 and was discharged on August 28, 2025. The individual treatment plan was due to be completed no later than April 30, 2025; however, the plan was not completed until May 29, 2025.
Client # 5 was admitted on April 1, 2025 and was discharged on June 25, 2025. The individual treatment plan was due to be completed no later than May 1, 2025; however, the plan was not completed until June 4, 2025.
Client # 6 was admitted on January 28, 2025 and was discharged on May 27, 2025. There was no individual treatment plan documented in the record at the time of the inspection.
Client # 7 was admitted on April 14, 2025 and was discharged on June 16, 2025. The individual treatment plan was due to be completed no later than May 15, 2025; however, the plan was not completed until June 2, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
3. In order to ensure that all initial Treatment Plans are completed within 30 days of admission, the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct 5 chart audits per month to verify completion. The Program Coordinator will send monthly reminders to staff. This will begin on 12/1/25.
All staff will be provided with re-training on documentation requirements regarding review treatment planning and the goal of completing it during the intake. Training will occur during individual and group supervision. This will occur by 12/15/25.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of three applicable client records reviewed.
Client # 1 was admitted on May 28, 2025 and was still active at the time of the inspection. The individual treatment plan was completed on July 16, 2025 and the first update was due no later than September 16, 2025; however, the update was not documented in the record at the time of the inspection.
Client # 3 was admitted on May 5, 2025 and was still active at the time of the inspection. A treatment plan update was completed on July 8, 2025 and the next update was due no later than September 8, 2025; however, the update was not completed until September 16, 2025.
Client # 4 was admitted on March 31, 2025 and was discharged on August 28, 2028. The individual treatment plan was completed on May 29, 2025 and an update was due no later than July 29, 2025; however, the update was not documented in the record prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
3. In order to ensure that all Master Treatment Plans are completed every 60 days from the initial treatment plan, the Program Director will create a document tracking tool.
This tool will auto populate due dates in order to support with timely completion.
All active clients from the audit will have completed preliminary by 12/5/25. The Drug and Alcohol Outpatient
Coordinator will conduct 5 chart audits per month to verify completion. The Program Coordinator will send monthly reminders to staff. This will begin on 12/1/25.
All staff will be provided with re-training on documentation requirements regarding review treatment planning and the goal of completing it during the intake. Training will occur during individual and group supervision. This will occur by 12/15/25.
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of case consultation notes, in three of four applicable client records reviewed.
The facility policy and procedure manual stated there will be case consultations completed for all clients every 90 days.
Client # 1 was admitted on May 28, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 4 was admitted on March 31, 2025 and was discharged on August 28, 2025. There were no case consultation notes documented in the record during the client's treatment episode.
Client # 6 was admitted on January 28, 2025 and was discharged on May 27, 2025. There were no case consultation notes documented in the record during the client's treatment episode.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
4. In order to ensure that all Case Consultation notes are completed every 90 days the Program Director will create a document tracking tool. This tool will auto populate case consultation due dates from the assessment date in order to support with timely completion.
All active clients will have completed Case Consult notes by 12/5/25.
The Drug and Alcohol Outpatient Coordinator will conduct 5 chart audits per month to verify completion. The Program Coordinator will send monthly reminders to staff. This will begin on 12/1/25.
All staff will be provided with re-training on documentation requirements regarding Case Consultation notes Training will occur during individual and group supervision. This will occur by 12/15/25.
|
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of two applicable client records reviewed.
The facility policy and procedure manual stated that follow-up activity will be completed within 7 days of discharge for all clients who successfully completed treatment.
Client # 5 was admitted on April 1, 2025 and was successfully discharged on June 25, 2025. There was no follow-up information documented in the record at the time of the inspection.
Client # 7 was admitted on April 14, 2025 and was successfully discharged on June 16, 2025. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
4. In order to ensure that all follow up contacts occur 7 days post-discharge, the Program Director will create a document tracking tool. The Drug and Alcohol Outpatient Coordinator will conduct 5 chart audits per month to verify completion. The Program Coordinator will send monthly reminders to staff. This will begin on 12/1/25.
All staff will be provided with re-training on documentation requirements regarding follow-up contacts post discharge. Training will occur during individual and group supervision. This will occur by 12/15/25.
|