INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 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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705.24 (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 on April 29, 2026, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. When tested, the hot water in a staff/client bathroom was 135.8 degrees Fahrenheit.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Our hot water heater was turned down and now when tested, water temperatures do not exceed 120 degrees Fahrenheit.
The Clinical Coordinator will check the water temperature monthly and if the temperature exceeds 120 degrees Fahrenheit she will alert the Facilities Director to make adjustments to the hot water heater. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of the facility ' s policy and procedure manual, the facility failed to develop a follow-up policy to include following up on all clients that had been discharged from the facility. The facility policy indicates that follow-ups are only completed on successful discharges. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy will be revised by July 20, 2026, to require that follow-up attempts be completed for all clients unless the client is incarcerated or deceased. The Clinical Director is responsible for revising the policy.
Once the revisions are complete our Clinical Manager will distribute the updated policy to all applicable staff and review the changes to ensure understanding and implementation.
Compliance with the revised policy will be monitored by the Clinical Coordinator and Clinical Supervisor through the discharge approval process and routine chart reviews. Any identified deficiencies will be addressed through supervision, coaching, and corrective action as needed to ensure ongoing compliance. |