INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Create Abilities 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and review of the personnel records, the facility failed to ensure that a written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
Employee #1 was hired on September 24, 2025 as the Project Director/Facility Director and was still in the position as of the date of the inspection. No plan was completed.
Employee #2 was hired on October 2, 2025 as a counselor and was still in the position as of the date of the inspection. No plan was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training plans were not completed as CADC is awaiting health insurance company credentialing to be completed. Project Director completed 5.5 hours of training since inspection. CADC fulfills yearly training requirements. Training plan will be completed upon 30days of new hires and monitored throughout the year. Project director created a training feedback form to accompany completed trainings.
How to prevent recur: Plans will be completed within 30 days of hire by Project Director. This error occured due to mistake of project director as program isn't up and running as we await insurance credentialing for client treatment. When staff are actively working with clients, all policies and procedures will be active. Training plans for next year will be completed by project director by 7/1/26 for the agency,self, and CADC. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #1 was hired on September 24, 2025 as the Project Director/Facility Director and was still in the position as of the date of the inspection. No training was completed.
Employee #2 was hired on October 2, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Training will be added to orientation list, review of appropriate training and capability will require signatures from staff member and project director. To be reviewed yearly.
Project director & CADC completed necessary fire extinguisher training on 5/19/26. Training will occur yearly on or before 5/19.
Training of new hires will occur within 7 days of being hired and reviewed annually. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #1 was hired on September 24, 2025 as the Project Director/Facility Director and was still in the position as of the date of the inspection. No training was completed.
Employee #2 was hired on October 2, 2025 as a counselor and was still in the position as of the date of the inspection. No training was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
fire drill instructions and expectations will be reviewed will each staff member. It will be added to orientation training, will signatures from staff and project director. Reviewed annually.
Training of ER procedures will occur within 7 days of hire, reviewed annually.
5/19/26 Project director and CADC reviewed ER policies, procedures to ensure appropriate response in emergency. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the September, 2025- May, 2026 fire drill logs during the inspection, the facility failed to document the time of the drill, problems encountered and whether or not the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project director modified the fire drill template to include time, functioning status of alarm, problems encountered. Project director reviewed and modeled with CADC how to fulfill requirements of monthly drills. Completed on 5/19/26. Project Director is responsible for completing most drills, CADC is required to complete 1 each calendar quarter. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in one out of one applicable records reviewed.
Client #1 was admitted on December 16, 2025 and was discharged on January 15, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
biopsychosocial was modified to include a clinical summary which is completed by CADC
Project director modified the template and informed CADC of the new requirement.
Project director will randomly audit charts to ensure compliance throughout the treatment process. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include, but not limited to, written documentation of frequency of treatment and rehabilitation services in one out of one client records reviewed.
Client #1 was admitted on December 16, 2025 and was discharged on January 15, 2026. A comprehensive treatment plan was developed on January 6, 2026 with no frequency identified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
the treatment plan has been reformatted to include frequency of treatment by project director. When the facility is actively treating clients, the project director will audit charts ensuring compliance. Project director informed CADC of the new requirement and will randomly audit charts to ensure compliance.
Action completed upon active client treatment, template was modified 5/19/26. |
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.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of one applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed 60 days following discharge.
Client #1 was admitted on December 16, 2025 and was discharged on January 15, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up letter was mailed to client on 5/13/26
To ensure this policy is fulfilled moving forward, Project director will maintain monthly supervision with CADC ensuring that Createabilities policy and procedures are fulfilled. |