INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2024 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, 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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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 within seven days of employment.
Employee #1 was hired on August 10, 2023 as the Project Director was still in the position as of the date of the inspection. The training was completed on September 1, 2023.
Employee #2 was hired on August 10, 2023 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 1, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
o Meadowlark Counseling Services, LLC will address this deficiency by updating the employee handbook, enacting a policy that requires all new employees receive Fire Extinguisher Training during their new employee orientation and within seven days of their date of hire. Additionally, each employee will sign a document stating they received this training and are competent in using a fire extinguisher if the need arises.
o Responsible Person: Dr. Joshua R. Battin
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from September 2023 through February 2024, the facility failed to conduct unannounced fire drills at least once a month. There were no unannounced fire drills occurring during the months of September, October and December, 2023 and January, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
o From the date of completion forward, all fire drills will be unannounced.
o Responsible Person: Dr. Joshua R. Battin
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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 task during emergencies within seven days of employment.
Employee #1 was hired on August 10, 2023 as the Project Director was still in the position as of the date of the inspection. The training was completed on September 1, 2023.
Employee #2 was hired on August 10, 2023 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 1, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
o Meadowlark Counseling Services, LLC will address this deficiency by updating the employee handbook, enacting a policy that requires all new employees receive training related to their tasks when an emergency occurs. This policy will require the training to take place during their new employee orientation and within seven days of their date of hire. Additionally, each employee will sign a document stating they received this training and are competent in these duties if the need arises.
o Responsible Person: Dr. Joshua R. Battin
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from September 2023 through February 2024, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same exit route, the front door.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
o From the date of completion forward, all exit routes (i.e., primary and alternate) will be utilized evenly during monthly fire drills.
o Responsible Person: Dr. Joshua R. Battin
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the September 2023 through February 2024 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill during the months of September and December 2023 and February 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
o From the date of completion forward, all fire drills will set off the fire alarm and document it has been completed.
o Responsible Person: Dr. Joshua R. Battin
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.
Client #4 was admitted on November 1, 2023 and was still active at the time of the inspection. A release of information form to a government agency did not document when the consent will expire.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
o By May 15, 2024, the document titled "Release of Information" will redact the line stating "date of expiration" and include a sentence above stating "expires after financial obligations have been met."
o Responsible Person: Dr. Emily R. Wheeler
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in two out of seven client records reviewed.
Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. A release of information form for a government entity signed January 9, 2024 did not have documentation that the client was offered a copy of the consent form.
Client #4 was admitted on November 1, 2023 and was still active at the time of the inspection. A release of information form to a government agency signed on November 1, 2023 did not document that the client was offered a copy of the consent form.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
o By May 15, 2024, the document titled "Release of Information" will remove all checkboxes identifying if the individual has been offered a copy, if they accept, or if they decline said copy.
o Responsible Person: Dr. Emily R. Wheeler
UPDATE:
Check box was deleted in front of "I have been offered a copy of this document and I have" accepted/declined" a copy
Training will be conducted to make sure all staff are completing the form correctly. |
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 seven out of seven records reviewed.
This findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
o By May 15, 2024, an updated biopsychosocial will be utilized for all clients coming to treatment. This biopsychosocial will include a text box at the end of the document with a header of "evaluation." It will be required to be completed prior to the biopsychosocial being signed.
o Responsible Person: Dr. Emily R. Wheeler
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the timeframe in the facilities policy and procedure manual seven out of seven records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed within 30 days of the first appointment.
This findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
o By May 15, 2024, an updated biopsychosocial will be utilized for all new clients. The biopsychosocial will be updated to add a preliminary treatment plan which will include the following goals:
Addiction
Supports
o By May 15, 2024 a new policy and procedure will be created by the clinic to include the preliminary treatment plan at evaluation. The policy and procedure will also be amended to include that a comprehensive treatment plan will be developed with the client by his or her 3rd individual session.
o Responsible Person: Dr. Emily R. Wheeler & Dr. Rebecca Parks
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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 type and frequency of treatment and rehabilitation services in four out of six client applicable records reviewed.
Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 11, 2024 with no type or frequency identified.
Client #2was admitted on September 22, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 22, 2023 with no type or frequency identified.
Client #3 was admitted on November 15, 2023 and still active at the time of the inspection. A comprehensive treatment plan was developed on November 26, 2023 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
o By May 15, 2024, the treatment plan will be updated to include type and frequency of treatment.
o Responsible Person: Dr. Emily R. Wheeler
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in six out of seven records reviewed.
Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 11, 2024.
Client #2was admitted on September 22, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 22, 2023.
Client #3 was admitted on November 15, 2023 and still active at the time of the inspection. A comprehensive treatment plan was developed on November 26, 2023.
Client #4 was admitted on November 1, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 1, 2023
Client #5 was admitted on October 18, 2023 and was discharged on February 9, 2024. A comprehensive treatment plan was developed on October 20, 2023.
Client #6 was admitted on November 1, 2023 and was discharged on January 16, 2024. A comprehensive treatment plan was developed on November 7, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
o By May 15, 2024, all treatment plans will include the treatment plan goal of "supports." A new treatment plan was previously developed before the audit which included this goal, however, old versions of the treatment plan were being utilized on occasion.
o Responsible Person: Dr. Emily R. Wheeler
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six records reviewed.
Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 11, 2024 and an update was due no later than March 11, 2024; however, none was completed.
Client #4 was admitted on November 1, 2023 and was still active at the time of the inspection. A treatment plan update was completed on January 9, 2024 and an update was due no later than March 9, 2024; however, none was completed.
Client #5 was admitted on October 18, 2023 and was discharged on February 9, 2024. A comprehensive treatment plan was completed on October 20, 2023 and an update was due no later than December 20, 2023; however, none was completed.
Client #6 was admitted on November 1, 2023 and was discharged on January 16, 2024. A comprehensive treatment plan was completed on November 7, 2023 and an update was due no later than January 7, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
o By May 15, 2024, an alert system will be implemented in the ECR to notify counselors 45 days after the 1st signature is placed on the treatment plan.
o Responsible Person: Dr. Emily R. Wheeler
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of four applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission and annually thereafter.
Client #2was admitted on September 22, 2023 and was still active at the time of the inspection. No case consultation was documented.
Client #3 was admitted on November 15, 2023 and still active at the time of the inspection. No case consultation was documented.
Client #4 was admitted on November 1, 2023 and was still active at the time of the inspection. No case consultation was documented.
Client #5 was admitted on October 18, 2023 and was discharged on February 9, 2024. No case consultation was documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
o By May 15, 2024, all clinical and supervisory staff will have a reoccurring appointment on his or her schedule for case review. Case review will occur on the 3rd Friday of every month to ensure that each individual is being reviewed every 90 days.
o A note template will be developed by May 15, 2024 for the case review.
o Responsible Person: Dr. Emily R. Wheeler
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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 two out of two applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 7 days following discharge for referred clients and 14 days for other clients.
Client #5 was admitted on October 18, 2023 and discharged on February 9, 2024. A follow up was due no later than February 25, 2024; however, none was completed.
Client #6 was admitted on November 1, 2023 and was discharged on January 16, 2024. A follow up was due no later than January 30, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
o By May 15, 2024, a letter will be developed for follow up to send to each client that is discharged both successfully and unsuccessfully
Clients that will not receive this letter include those who are incarcerated, decease or inpatient.
o By May 15, 2024, the policy and procedure manual will be updated to amend the 7 day time frame to 21 days post discharge.
o By May 15, 2024, a pamphlet of available resources will be developed to send to the discharged client with the letter.
o Responsible Person: Dr. Emily R. Wheeler & Dr. Rebecca Parks
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