INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4, 2026, 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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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 a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within 30 days of first session, per facility policy, in six of seven records reviewed.
Client #1 was admitted to the outpatient activity on July 9, 2025 and was discharged on September 29, 2025. A psychosocial evaluation was not documented in the client record.
Client #2 was admitted to the outpatient activity on May 19, 2025 and was discharged on July 21, 2025. A psychosocial evaluation was not documented in the client record.
Client #3 was admitted to the outpatient activity on April 2, 2025 and was discharged on June 16, 2025. A psychosocial evaluation was not documented in the client record.
Client #4 was admitted to the outpatient activity on May 19, 2025 and was discharged on July 14, 2025. A psychosocial evaluation was not documented in the client record.
Client #5 was admitted to the outpatient activity on September 8, 2025 and was active during licensing process. A psychosocial evaluation was not documented in the client record.
Client #6 was admitted to the outpatient activity on July 14, 2025 and was active during licensing process. A psychosocial evaluation was not documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Biopsychosocial Assessments were conducted for all clients referenced in the citation. However, the required summary section was documented within a different area of the client's electronic health record rather than within the Biopsychosocial Assessment itself.
During Meadowlark Counseling Services' review of policies and procedures in the summer of 2025, the agency identified this workflow issue and requested that our electronic health record system, DENmaar, modify the Biopsychosocial Assessment template to include a designated summary section within the assessment form.
As a result of this modification, all Biopsychosocial Assessments completed on or after January 15, 2026 (update version 8.21.17) include the required summary within the assessment document. This change ensures the summary is contained directly within the Biopsychosocial Assessment and addresses the documentation deficiency cited.
The Clinical Supervisor will continue to review documentation through routine chart audits to ensure ongoing compliance with assessment documentation requirements. This plan of correction is effective March 20, 2026 and overseen by the Clinical Supervisor.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in two of three applicable records reviewed.
Client #1 was admitted to the outpatient activity on July 9, 2025 and was discharged on September 29, 2025. The client record did not contain documentation of a completed aftercare plan.
Client #4 was admitted to the outpatient activity on May 19, 2025 and was discharged on July 14, 2025. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with Meadowlark Counseling Services' Policies and Procedures, a Termination/Reengagement letter is sent to clients when a loss of contact occurs. Clients are provided ten (10) days to reengage in services. If the client does not respond within ten days, the client is discharged from services for a minimum of 45-days.
To address the deficiency cited, Meadowlark Counseling Services will ensure that all discharge correspondence sent to clients include a documented aftercare plan. For successful discharge, the aftercare plan will be completed and provided to the client before or at the final session. For any unsuccessful discharge clients, a generic aftercare plan will be mailed to the most recent address on file. All aftercare plans will include a list of drug, alcohol, and mental health providers in the area, and crisis information including the county crisis line.
Additionally, Meadowlark Counseling Services will revise its Policies and Procedures to require that a staff member attempt to contact the discharged client by telephone within sixty (60) days of discharge to inquire about the client's status, progress, and any need for additional services or reengagement in treatment.
The Clinical Supervisor will review discharge documentation as part of routine chart audits to ensure that aftercare planning and follow-up procedures are consistently implemented and maintained. This plan of correction is effective March 20, 2026 and overseen by the Clinical Supervisor.
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