INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24, 2025, 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.
Employee # 2 was promoted to the position of clinical supervisor on June 1, 2024 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree, but only one year of clinical experience, not the required minimum of three years.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current clinical supervisor has obtained their master's degree on 5/18/25 and currently meets the qualifications of clinical supervisor. All management staff were retrained on the qualifications of clinical supervisor on 5/18/25 during a staff meeting. Moving forward, the Executive Director is responsible for ensuring that all new hires or promoted staff meet the qualifications of their perspective roles. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision which is a requirement for the position.
Employee # 2 was promoted to the position of clinical supervisor on June 1, 2024 and is current in that position. Employee # 2 did not function for 2 years as a supervisor and has not completed a core curriculum as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Clinical supervisor will obtain required training by June 16th.
The management staff were retrained on the appropriate trainings required for all staff on 5/8/25 during a staff meeting. The Executive Director will ensure all required training for supervisors are properly given to staff and obtained within a timely matter. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of eight personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee # 6 was hired as a counselor on January 6, 2025 and was current in that position at the time of the inspection. At the time of hire, the employee did not complete the minimum educational requirements for the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 since inspection has since obtained a bachelor's degree in psychology on 5/15/2025 and meets the qualifications for counselor. All management and hiring staff were retrained during a staff meeting on 5/8/25 regarding the qualifications of all positions. The Executive Director will review all potential new hires qualifications to ensure that they meet the requirements. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a discussion with facility staff and a review of administrative documents, the facility failed to ensure that an overall plan for addressing staff training needs was completed by January 31, 2025, per policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For the current training year, a staff meeting was held with all staff on 5/16/25 where the staff were surveyed on training needs. The information from the survey was collected by the executive team and an overall plan for addressing staff trainings needs was developed on 5/19/25 for the remainder of the year.
Moving forward, the first Friday of every December, a full staff meeting will be held in which staff training needs will be assessed. The executive team will obtain the information of staff training need and develop and overall plan by January 1st of each year. The Executive Director and Compliance Coordinator will be responsible for maintaining ongoing yearly compliance. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of eight personnel records, the facility failed to demonstrate that a sufficient number of staff persons had first aid training, as only one staff member was certified in CPR prior to March 24, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All full time staff will complete CPR and First Aid training by 6/30/2025. All new staff will be notified during the onboarding process that they should obtain CPR/First Aid training within 90 days of employment. Program director will be responsible for monthly training audits to ensure that sufficient staff are trained in CPR/ First Aid. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. At the time of the inspection, there was no annual financial audit completed for the facility's fiscal year ending on December 31, 2023.
This is a repeat citation from the May 7, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The independent accountant has been obtained as the independent accountant services as of January 2025. The accounting firm is currently working on the fiscal report for 2023 and will have it completed by 11/30/25. The independent accounting firm will continue ongoing fiscal monitoring of the program and will have the fiscal year's audit completed and on file by June 30th of the following year each year. The Regional Director will be responsible for monitoring ongoing compliance of the fiscal monitoring. |
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 fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 14 was transferred to the outpatient level of care on December 16, 2024 and was active at the time of the inspection. The record contained a release of information form to the funding source that was signed and dated by the client on July 26, 2024, and expired on January 24, 2025; however, there was evidence of disclosures to the funding source after the release form expired.
This is a repeat citation from the May 7, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation 709.28 was reviewed with all staff during staff meeting on 5/15/25. Weekly chart audits will be performed by program coordinator and staff member during clinical supervision. Release of information will be checked during chart audits as well as obtained as needed any new sources identified. Releases of information will be checked by every clinician prior to releasing information to any source. All active client charts will have updated releases of information completed by 6/15/25. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of fourteen client records, the facility failed to ensure that consent to release information forms included the name of the person, agency or organization to whom disclosure is to be made in one record reviewed.
Client # 5 was admitted to the partial hospitalization level of care on December 2, 2024 and was transferred to a lower level of care on December 16, 2024. A consent to release information form that was signed and dated by the client on November 26, 2024, was missing documentation of the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation 709.28 was reviewed with all staff during staff meeting on 5/15/25. Weekly chart audits will be performed by program coordinator and staff member during clinical supervision. Release of information will be checked during chart audits, specifically identifying that the person, agency or organization to whom the disclose is to be released is filled out in its entirety; as well as obtain any new sources identified, as needed. Releases of information will be checked by every clinician prior to releasing information to any source.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of fourteen client records, the facility failed to ensure that consent to release information forms included the information to be disclosed in two records reviewed.
Client # 2 was admitted to the partial hospitalization level of care on November 26, 2024 and was transferred on December 16, 2024. A consent to release information form to another treatment provider was signed and dated by the client on November 26, 2024, that was missing documentation of the specific information to be disclosed.
Client # 5 was admitted to the partial hospitalization level of care on December 2, 2024 and was transferred to a lower level of care on December 16, 2024. A consent to release information form to an outside party was signed and dated by the client on November 26, 2024, that was missing documentation of the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation 709.28 was reviewed with all staff during staff meeting on 5/15/25, specifically reviewing the section of the information to be disclosed. Weekly chart audits will be performed by program coordinator and staff member during clinical supervision. Releases of information will be checked during chart audits, specifically checking that the information to be disclosed is completed in its entirety. Releases of information will be checked by every clinician prior to releasing information to any 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 fourteen client records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in four records reviewed.
Client # 2 was admitted to the partial hospitalization level of care on November 26, 2024 and was transferred on December 16, 2024. A consent to release information form to another treatment provider was signed and dated by the client on November 26, 2024, that did not document of the purpose of disclosure.
Client # 5 was admitted to the partial hospitalization level of care on December 2, 2024 and was transferred to a lower level of care on December 16, 2024. A consent to release information form to an outside party was signed and dated by the client on November 26, 2024, did not document of the purpose of disclosure.
Client # 6 was admitted to the partial hospitalization level of care on April 16, 2025 and was active at the time of the inspection. A consent to release information form to a treatment provider was signed and dated by the client on April 16, 2025, did not document the purpose of disclosure.
Client # 7 was admitted to the partial hospitalization level of care on April 9, 2025 and was active at the time of the inspection. A consent to release information form to a treatment provider was signed and dated by the client on or about April 9, 2025, as the date was not legible, did not document the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation 709.28 was reviewed with all staff during staff meeting on 5/15/25, specifically reviewing the purpose of the disclosure on the release of information. Weekly chart audits will be performed by program coordinator and staff member during clinical supervision. Release of information will be checked during chart audits, specifically checking the the purpose of disclose is completed in its entirety. Releases of information will be checked by every clinician prior to releasing information to any source. The program coordinator will be responsible for ensuring that all active clients have updated releases of information completed by 6/15/25.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that clients have the right to inspect their own records, in eleven of eleven applicable records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights document was updated by program director on 4/30/25 to include all areas of the 709.30 Regulation of client rights. This updated document was reviewed with all staff on 5/15/25 and will be implemented at each intake appointment beginning on 5/20/25. Program coordinator will complete monthly chart audits to ensure that the updated version of client rights is being completed at intake for all clients served. All active client will complete an updated client rights document with their primary counselor by 6/20/25. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an onsite licensing inspection, the facility failed to develop a data collection and recordkeeping system that allowed for the identification of client ' s admissions and discharges within a specific time period. At the time of the inspection, the list of active and discharged clients provided by the facility included dates when the clients were receiving services at different facilities within the Project. Additionally, the provided client lists did not include all clients who received services at the facility within the period reviewed. For example, clients who received services in the partial hospitalization level of care at the facility, but were active in another facility within the Project, were not included on the lists provided.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director will submit an application to combine the licenses of 237109 and 237106 by 6/30/25 to reduce the transfers of client services between the two facilities. On 5/15/25, all staff were educated on entering miscellaneous notes for any discharges or transfer to another facility to ensure that any changes in services can be easily followed through the client's chart. Program coordinator will be responsible for ensuring that all documentation is completed in a timely matter through weekly chart audits. |
709.81(b)(7) LICENSURE Intake and admission
709.81. 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 and rehabilitation plan, as part of their intake and admission process, in four of seven applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization level of care on March 24, 2025 and was discharged on April 8, 2025. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
Client # 3 was admitted to the partial hospitalization level of care on January 15, 2025 and was discharged on January 30, 2025. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
Client # 6 was admitted to the partial hospitalization level of care on April 16, 2025 and was active at the time of the inspection. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
Client # 7 was admitted to the partial hospitalization level of care on April 9, 2025 and was active at the time of the inspection. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were educated and retrained during staff meeting on 5/15/25 regarding the regulation and policy in reference to timely completion of all treatment plans (preliminary, initial, updated). The program coordinator will conduct weekly chart audits and address any late entries in individual supervision with each staff member. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling sessions two times weekly for clients in the partial hospitalization level of care in seven of seven client records reviewed. The facility ' s policy and procedures manual indicated that the treatment weeks begins on the day of admission.
Client # 1 was admitted to the partial hospitalization level of care on March 24, 2025 and was discharged on April 8, 2025. The record contained documentation of only one individual session for the week of March 24, 2025, and did not contain documentation of any individual sessions the week of March 31, 2025.
Client # 2 was admitted to the partial hospitalization level of care on November 26, 2024 and was transferred on December 16, 2024. The record did not contain documentation of any individual sessions for the treatment weeks of November 26, 2024 and December 3, 2024.
Client # 3 was admitted to the partial hospitalization level of care on January 15, 2025 and was discharged on January 30, 2025. The record did not contain documentation of any individual sessions for the treatment week of January 15, 2025.
Client # 4 was transferred to the partial hospitalization level of care on February 27, 2025 and was transferred to a lower level of care on March 11, 2025. The record did not contain documentation of any individual sessions for the treatment week of February 27, 2025.
Client # 5 was admitted to the partial hospitalization level of care on December 2, 2024 and was transferred to a lower level of care on December 16, 2024. The record did not contain documentation of any individual sessions for the treatment week of December 2, 2024.
Client # 6 was admitted to the partial hospitalization level of care on April 16, 2025 and was active at the time of the inspection. The record contained documentation of only one individual session for the treatment week of April 16, 2025.
Client # 7 was admitted to the partial hospitalization level of care on April 9, 2025 and was active at the time of the inspection. The record did not contain documentation of any individual sessions for the treatment week of April 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been retrained and educated during staff meeting on 5/15/25 regarding the expectation of individual sessions in PHP level of care and appropriate documentation of any missed treatment sessions. Additional staff have been added to PHP program in order to ensure compliance. Program coordinator will complete weekly chart audits and address any late entries in individual supervision with each staff member. |
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 and rehabilitation plan, as part of their intake and admission process, in two of two applicable client records reviewed.
Client # 10 was admitted to the outpatient level of care on August 14, 2024 and was discharged on September 17, 2024. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
Client # 11 was admitted to the outpatient level of care on August 13, 2024 and was discharged on September 30, 2024. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection.
This is a repeat citation from the May 7, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were educated and retrained during staff meeting on 5/15/25 regarding the regulation and policy in reference to timely completion of all treatment plans (preliminary, initial, updated). The program coordinator will conduct weekly chart audits and address any late entries in individual supervision with each staff member. |
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 two of three applicable records reviewed.
Client # 8 was admitted to the outpatient level of care on June 10, 2024 and was discharged on March 25, 2025. A treatment plan update was completed on October 31, 2024 and the next treatment plan update was due to be completed by December 30, 2024; however, no additional treatment plan updates were completed prior to discharge.
Client # 14 was transferred to the outpatient level of care on December 16, 2024 and was active at the time of the inspection. A treatment plan update was completed on December 26, 2024, and the next treatment plan update was due to be completed by February 24, 2025; however, the treatment plan update was not completed until March 6, 2025.
This is a repeat citation from the May 7, 2024, May 23, 2023, and May 16, 2022 annual licensing renewal inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All staff were educated and retrained during staff meeting on 5/15/25 regarding the regulation and policy in reference to timely completion of all treatment plans (preliminary, initial, updated). The program coordinator will conduct weekly chart audits and address any late entries in individual supervision with each staff member. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to review and update treatment and rehabilitation plans at least every sixty days was submitted and approved by the Department for the May 7, 2024, May 16, 2022, and May 23, 2023 licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the April 24, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Regional Director completed a root cause analysis for the plan of correction that was not met. Findings were that due to staff turnover and short staffing, the original plan of correction was unsuccessful. Moving forward, all managers will be meeting on a bi-weekly, basis, beginning on 5/21/25, to review chart audits, treatment plan compliance and all client documentation needs. The regional director will be responsible for the ongoing meetings and maintaining compliance with all POC. Any areas of concern will be addressed in the managers meeting in real time to be addressed with direct staff members by their direct supervisor. |