INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 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 April 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?
UPDATE: This has already been corrected which is the reason for the date being prior to today.
Clinical Director will be responsible for ensuring that the corrective action plan is implemented immediately. |
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 three of the seven records reviewed.
Client #1 was admitted on October 16, 2024 and discharged January 31, 2025. There was documentation that information was disclosed to a mental health provider on December 16, 2024, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.
Client #6 was admitted on admitted on December 16, 2024, and discharged on January 13, 2025. There was documentation that information was disclosed to the funding source on December 16, 2024, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.
Client #7 was admitted November 4, 2024, and still active at the time of the inspection. There was documentation that information was disclosed to a mental health provider on November 12, 2024, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information until November 18, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Prior to April 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.
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 April 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.
UPDATE TO INCLUDE: All client ROI's will be reviewed by 4/1/25. Further, all clients will be requested to sign updated and complete ROI's at their first appointment attended.
Clinical Director will be responsible for ensuring that the corrective action plan is implemented immediately.
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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 which included the purpose of the disclosure in three out of seven records reviewed.
Client #2 was admitted on March 28, 2024 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to the housing authority, signed and dated August 14, 2024, did not include the purpose of disclosure.
Client #5 was admitted on September 26, 2024 and discharged December 11, 2024. An informed and voluntary consent from the client for the disclosure of information to a parole office signed and dated September 26, 2024, did not include the purpose of disclosure.
Client #7 was admitted on November 4, 2024 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to the emergency contact, signed and dated November 4, 2024, did not include the purpose of disclosure.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Prior to April 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 April 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.
UPDATE TO INCLUDE: All client ROI's will be reviewed by 4/1/25. Further, all clients will be requested to sign updated and complete ROI's at their first appointment attended.
Clinical Director will be responsible for ensuring that the corrective action plan is implemented immediately.
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