INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MVP Recovery 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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709.28 (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 include the purpose of the disclosure on a consent to release information form in one of seven client records reviewed. Client #1 was admitted on August 12, 2025 and was discharged on November 14, 2025. There was a release of information form to another treatment provider signed and dated by the client on August 12, 2025; however, there was no purpose of the disclosure documented on the release form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director reviewed the proper completion of all releases of information during staff meeting on 5/1/26. The program director reviewed confidentiality regulations and adherence to the proper completion of releases of information. Program director will conduct monthly chart audits to ensure that the releases of information are in compliance and will address any concerns with staff directly. If any releases are found to be incomplete, they will be updated to completion. |
709.92(a) 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:
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client or was completed per facility policy in three of seven client records reviewed. The facility's policy and procedure manual stated a client will receive an intake session within 7 days of completing the Client Initial Screening Form and the Client Comprehensive Treatment Plan will be completed within 14 days of intake.Client #3 was admitted on September 3, 2025 and discharged on December 18, 2025. The initial screening form was completed on September 2, 2025. According to facility policy, the individual treatment plan was due to be completed no later than September 22, 2025; however, the plan was completed on November 6, 2025. Additionally, there was no written documentation in the record indicating the plan was developed with the client.Client #4 was admitted on September 29, 2025 and discharged on January 12, 2026. There was no documentation in the record indicating an individual treatment plan was completed with the client prior to discharge. Client #7 was admitted on January 21, 2026 and was active at the time of the inspection. The initial screening form was completed on January 21, 2026. According to facility policy, the individual treatment plan was due to be completed at least by February 12, 2026; however, the plan was completed on March 23, 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director reviewed treatment plan policy and timeliness of treatment plans with all staff during staff meeting on 5/1/26. Program director will complete monthly chart audits to ensure compliance and timeliness of treatment plans. Program Director will address any concerns of non compliance during individual supervision with staff members and provide support and coaching to meet treatment plan requirements. |