INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19-20, 2025, 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 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to have staff persons receive a minimum of 6 hours of HIV/AIDS training using a department approved curriculum within the first year of employment, in one of five personnel records reviewed.
Employee #5 was hired on July 9, 2024 and was still current in that position. Employee #5 did not have the required HIV training at the time of the licensing process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In our weekly Clinical Team meeting on Tuesday, 9/16/25, Clinical/Executive Director, reviewed the training requirements for the position of Counselor. A review of training sites and how to find and register trainings was done with all Clinical staff. Employee #5 completed her HIV training on 10/30/2025. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to have a counselor complete the required minimum of at least 25 clock hours of training annually in one of five personnel records reviewed.
Employee #5 was hired on July 9, 2024 and was current in that position. The personnel record indicated only 22.5 hours of annual training at the time of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In our weekly Clinical Team meeting on Tuesday, 9/16/25, Clinical/Executive Director reviewed the training requirements for the position of Counselor. A review of training sites and how to find and register trainings was done with all Clinical staff. Employee #5 was met with individually following the meeting, and a review of her Personal Training plan was done. She expressed an understanding of the expectations and shared that she was under hours due to a few trainings being canceled. A game plan for registered for well over 25 hours of trainings was devised, so that she will still meet the requirement should any trainings get canceled. Outpatient Clinical Supervisor will ensure that all Clinicians are on track to meet their training requirements as laid out in their annual training plans. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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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 to include in writing the purpose of disclosure in three out of fourteen client records reviewed.
Client #2 was admitted to the outpatient program on January 21, 2025 and was active at the time of licensing inspection. A release of information form to spouse was signed by the client on January 24, 2025, however the form did not include the purpose of the disclosure.
Client # 11 was admitted to the partial hospitalization activity on May 19, 2025 and was discharged on June 9, 2025. A release of information form to spouse was signed by the client on May 19, 2025, however the form did not include the purpose of the disclosure.
Client #12 was admitted to the partial hospitalization activity on July 17, 2025 and was active at time of licensing inspection. A release of information form to a mental health provider was signed by the client on July 17, 2025, however the form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 5, 2024 and September 13, 2023 licensing inspection.
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Plan of Correction
In our weekly Clinical Team meeting on Tuesday, 9/16/25, Clinical/Executive Director reviewed Confidentiality requirements and the purpose behind the various sections of a Release. Education around each section (party to whom information shall be released, the type of information to be released, and the purpose of why the information will be released), was provided.
In addition to the Clinical Supervisor reviewing 30% of all new admissions, the Executive Director will also audit an additional 30% new admits, in order to review if this is being done properly.
As for current charts with incomplete ROI's, each Counselor has been instructed to audit all of their active clients. Any ROI's that are not completed properly, need to be redone with the client. This must be complete no later than 10/17/2025. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of outpatient client records, the facility failed to follow their written procedures to complete progress notes within 72 hours of counseling session in four out of seven applicable client records reviewed.
Client #1 was admitted to the outpatient program on November 26, 2024 and was still active at the time of the licensing inspection. The record identified individual sessions occurring on January 20, 2025, March 4, 2025, March 10, 2025, May 19, 2025, and July 15, 2025, that were not documented until January 27, 2025, March 11, 2025, March 18, 2025, May 26, 2025, and July 22, 2025, respectively.
Client #2 was admitted to the outpatient program on January 21, 2025 and was still active at the time of the licensing inspection. The record identified an individual session occurring on February 28, 2025, that was not documented until March 11, 2025.
Client #3 was admitted to the outpatient program on February 10, 2025 and was still active at the time of the licensing inspection. The record identified individual sessions occurring on March 14, 2025, and May 20, 2025, that were not documented until March 21, 2025, and March 11, 2025, respectively.
Client #5 was admitted to the outpatient program on April 22, 2025 and was discharged on June 25, 2025. The record identified individual sessions occurring on April 30, 2025, May 14, 2025, and June 4, 2025 that were not documented until May 7, 2025, May 20, 2025, and June 10, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on 9/16/2025, Clinical/Executive Director reviewed the internal policy of progress notes and other client-related documentation needing to be entered within 72 hours of the service being delivered. Each Clinician reviewed their schedule in that moment and identified documentation/case management time they have blocked off in their schedules to allow for this.
Clinical Team was informed that Director will be doing random, routine chart audits on a weekly basis. One group session note and 3 individual progress notes, will be pulled for each Counselor, from the preceding week, and reviewed for timely documentation.
If a Counselor continues to struggle to have timely documentation (within 72 business hours of the service being delivered), they will receive counseling and will be placed on a Performance Improvement Plan. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for documenting the purpose of disclosure on release of information forms, was submitted and approved by the Department for the August 5, 2024, and September 13, 2023, annual licensing inspections. Documenting the purpose of disclosure on release of information forms was again found to be a deficiency during the August 19-20, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CEO will meet with ED monthly to review and ensure POC's are being implemented as designed. |