INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2026 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 (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 fire extinguishers upon staff employment in one of three applicable personnel records reviewed. Employee #6 was hired as a counselor on June 9, 2025. The fire extinguisher training was due to be completed upon staff employment; however, the documentation provided indicated the training was provided to the employee on January 14, 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Coordinator will log into the Holcomb training system and verify that all new hires have completed orientation training (including the fire extinguisher training) before clearing the staff to begin seeing clients as part of their onboarding. |
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 were trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.Employee #6 was hired as a counselor on June 9, 2025. The training to perform assigned tasks during emergencies documentation provided indicated the training was provided to the employee on January 14, 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Coordinator will log into the Holcomb training system and verify that all new hires have completed orientation training (including the training to perform assigned tasks during emergencies) before clearing the staff to begin seeing clients as part of their onboarding. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's January 2025 through December 2025 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The facility's hours of operation are Monday through Friday 8:30AM to 8:00PM. Every fire drill conducted, during the reviewed period, was completed prior to 4:17PM. There were no fire drills conducted during the evening hours of operation. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be on a rotation moving forward to cover all shifts. Fire drills will be documented on the log and checked upon completion by the Coordinator, Manager and Director to ensure that they vary in terms of days, shifts and exits. |