INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19-20, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Little Creek Outpatient Services Llc 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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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 from the client for the disclosure of information contained in the client record in one out of fourteen records reviewed.
Client #5 was admitted to the partial hospitalization program on July 29, 2026 and was active at the time of the licensing process. A release of information form for the funding source was not documented in the client record. The facility confirmed billing had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In a clinical team meeting on 9/8/26, Clinical Director reviewed with the team the importance of taking our time and being thorough in completing all necessary ROI's for entities that will be involved in the client's care. Additionally, the Funding ROI which auto-populates in a new client chart to be complete, was shown to the clinical team for review.
For the next 6 months, the Clinical Director will review 100% of all ROI's in client charts in an effort to ensure they are being completed accurately and thoroughly.
If 100% of ROI's over those 6 months are completely properly, Clinical Director will return to routine chart audits of 30% of all charts. If improvement is not demonstrated, 100% of all ROI's will continue to be reviewed. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of age, creed, color, or national origin in ten of ten applicable records reviewed.
There was no documentation in the client records reviewed, that the client had been notified that the project may not discriminate in the provision of services on the basis of age, creed, color, or national origin.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 09/04/26, the Client Rights and Responsibilities form was updated by the Clinical Director to include language taken directly from PA State Code 709.30 Client Rights:
The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
All current client records were updated to include the new Rights and Responsibilities on 9/14/26. Primary Counselors will review the form with their clients at their next individual session, and clients will sign them. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in ten of ten applicable records reviewed.
There was no documentation in the client records reviewed, that the client had been notified of their right to inspect their own records and that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 09/04/26, the Client Rights and Responsibilities form was updated by the Clinical Director to include language taken directly from PA State Code 709.30 Client Rights.
The form now reads:
All clients have the right to inspect your own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
All current client records were updated to include the new Rights and Responsibilities on 9/14/26. Primary Counselors will review the form with their clients at their next individual session, and clients will sign them.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in eleven of eleven applicable records reviewed.
There was no documentation in the client records reviewed, that the client had been notified of their right to submit rebuttal data or memoranda to their own records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 09/04/26, the Client Rights and Responsibilities form was updated by the Clinical Director to include language taken directly from PA State Code 709.30 Client Rights. The form now reads:
Clients have the right to appeal a decision limiting access to their records to the director.
To request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Clients have the right to submit rebuttal data or memoranda to their own records.
All current client records were updated to include the new Rights and Responsibilities on 9/14/26. Primary Counselors will review the form with their clients at their next individual session, and clients will sign them. |