INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Meadowlark Counseling 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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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 review of fire drill logs from March 2024 through December 2024, the facility failed to maintain a written fire drill record that included the time of the drill for the months of June 2024 through December 2024.
This finding was reviewed with the facility staff during the licensing process
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Plan of Correction
Prior to May 1, 2025, Meadowlark Counseling Services will develop a fire drill log with columns including the following information: date of drill, time of drill, amount of time it took for evacuation, the exit routes utilized, number of persons in the facility at the time of the drill, problems encountered and the success of the operation. The chart will look as follows:
Date Time Time for Evacuation Exit Routes Used People in Facility Problems Encountered Fire alarm Operative?
Dr. Emily R. Wheeler will be responsible for updating the table associated with the fire drill log.
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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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed.
Client #5 was admitted on October 03, 2024, and was still active at the time of the inspection. There was documentation of a disclosure of information to the funding source on October 29, 2024; however, there was not an informed and voluntary consent from the client for the disclosure of that information in the record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Prior to May 1, 2025, Meadowlark Counseling Services will update policy and procedures for intake to include a release of information done at intake for all Medicaid, self-pay/clients without insurance, and SCA clients to include the following releases of information:
- County SCA
- CCBH
- Managed Care Provider
This updated policy and procedure will be reviewed by all staff at staff meeting.
Dr. Emily R. Wheeler will be responsible for the aforementioned training.
EDIT TO ADD: By May 1, 2025, all current active clients will sign a release of information for CCBHO if they are Medicaid recipients. Further, all current active clients will sign a release of information for the county SCA if this is the funding source.
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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 that included the purpose of disclosure in one of seven records reviewed.
Client #3 was admitted on June 27, 2024 and discharged on August 27, 2024. Informed and voluntary consent to disclose information forms signed and dated on June 27, 2024, for a treatment center and an emergency contact did not include the purpose of disclosure.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Prior to May 1, 2025, Meadowlark Counseling Services will conduct a training regarding the correct documentation of releases of information. This training will occur at a staff meeting prior to May 1, 2025, and all staff will be required to sign a statement that they have been trained on the correct documentation for a ROI. The training will include information regarding client name, name or location of individual to which information will be released, address of individual or location to which information will be released, purpose of release, information able to be released, signature and date of client, as well as signature and date of witness.
Dr. Emily R. Wheeler will be responsible for the aforementioned training.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of the client in one out of seven records reviewed.
Client #4 was admitted on December 5, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated December 5, 2024 for a funding source, public defender ' s office, and emergency contact had a witness signature, but did not include the dated signature of the client. The facility confirmed disclosure had occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to May 1, 2025, Meadowlark Counseling Services will conduct a training regarding the correct documentation of releases of information. This training will occur at a staff meeting prior to May 1, 2025, and all staff will be required to sign a statement that they have been trained on the correct documentation for a ROI. The training will include information regarding client name, name or location of individual to which information will be released, address of individual or location to which information will be released, purpose of release, information able to be released, signature and date of client, as well as signature and date of witness.
Dr. Emily R. Wheeler will be responsible for the aforementioned training.
EDIT TO ADD: By May 1, 2025, each active client record will be reviewed by the clinical director for QA assurance. Each patient record that is missing required information for a complete ROI will be updated with new patient signature.
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