INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17-18, 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 Lodge 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for contacting the client 's emergency contact within twelve hours of a client leaving against medical advice in one of one applicable record reviewed.
Client #10 was admitted to the non-hospital residential level of care on July 6, 2026, and discharged Against Medical Advice (AMA) on August 2, 2026.. The facility failed to document the emergency contact was contacted within twelve hours.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In a Clinical Team meeting on Monday 8/31, Director reviewed with the treatment team the policy around needing to contact a client's Emergency Contact within 12 hours of an AMA discharge. All members communicated their understanding of this policy and the importance of documenting that communication in the client record.
Moving forward, the Clinical Director will review all AMA discharges within 12 hours after discharge to ensure the Emergency Contact was properly notified and that communicated documented. Clinical Director will do this for no less than 6 months to ensure this is happening at 100%.
After 6 months, normal chart audits will resume as usual with 30% of all discharged charts being audited. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained an annual written performance evaluation, completed at 90 days after hire and annually thereafter based on the date of the 90 day evaluation, per facility policy, that was reviewed and signed by the employee in one of three applicable records reviewed.
Employee # 2 ' s original hire date was April 18, 2011, and was promoted to lead counselor on January 1, 2014, and was current in that position at the time of the inspection. Employee #2 ' s annual written performance evaluation was due April 1, 2026; however, the last documented evaluation was dated July 28, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 received his annual review that was past due on 9/3/26.
Additionally, on this date, our internal policy was amended by Project Director to include wording that the annual review will occur within 12 months from their previous review, rather than at the 12-month mark. Annual Reviews are performed by the Operations Manager and/or Project Director. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of the disclosure in two out of fourteen client records reviewed.
Client # 6 was admitted to the detox program on August 11, 2026, and was active at the time of the licensing inspection. A release of information form to an outside individual was signed by the client on August 11, 2026, but the release form did not include the purpose of the disclosure. A note in client record dated August 16, 2026, confirmed contact was made.
Client #10 was admitted to the non-hospital residential level of care on July 6, 2026, and discharged on August 2, 2026. A release of information form to an outside individual was signed by the client on July 6, 2026, but the release form did not include the purpose of the disclosure. Notes in client record dated July 7, 2026, July 14, 2026, July 21, 2026, and July 30, 2026 confirmed contact was made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a clinical team meeting on 8/31/26, Clinical Director reviewed with the team the importance of taking our time and being thorough in completing ROI's properly, being sure to complete all sections.
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 eleven of eleven applicable records reviewed.
The 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. These were reviewed with Clients by their Primary Counselors and signed by clients. |
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 eleven of eleven 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.
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. These were reviewed with Clients by their Primary Counselors and signed by clients.
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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 client 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. These were reviewed with Clients by their Primary Counselors and signed by clients. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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 client records and the facility policy manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed with 72 hours after therapy sessions, per facility policy, in four out of seven records reviewed.
Client # 8 was admitted to the non-hospital residential level of care on October 24, 2025, and discharged on November 21, 2025. The record contained progress notes for individual sessions occurring on November 6, 2025, and November 21, 2025, that were not completed until Nove 11, 2025 and December 19, 2025, respectively.
Client #10 was admitted to the non-hospital residential level of care on July 6, 2026, and discharged on August 2, 2026. The record contained progress notes for individual sessions occurring on July 15, 2026, July 22, 2026, and July 29, 2026, that were not completed until July 24, 2026, July 26, 2026, and August 2, 2026, respectively.
Client #11 was admitted to the non-hospital residential level of care on December 12, 2025, and discharged on January 12, 2026. The record contained a progress note for individual session occurring on December 15, 2025, that was not completed until December 25, 2025.
Client #12 was admitted to the non-hospital residential level of care on July 21, 2026, and was active at the time of licensing process. The record contained progress notes for individual sessions occurring on July 26, 2026, and August 1, 2026, that were not completed until August 8, and August 9, 2026, respectively.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 19, 2025, annual licensing inspection.
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Plan of Correction
In a clinical team meeting on 8/31/26, Clinical Director reviewed the policy on submitting progress notes within 72 hours from the date of the session. Clinical Director directed Counselors to submit their weekly therapy schedule on Monday mornings and then to contact the Clinical Director once the session note is documented. Clinical Director will utilize their individual schedules and reference emails to ensure progress notes are being submitted on it. This plan will be utilized for no less than 6 months to ensure progress in timeliness documentation. |