INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 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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704.11(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. |
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 a review of the June 2024 through March 2025 fire drill logs, the facility failed to document the exit route used during the January 2025 through March 2025 fire drills. Additionally, the fire drill logs for February 2025 and March 2025 did not contain documentation of the time to evacuate.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill logs were updated on 5/2/25 to include the exit route used and the length of time to evacuate during fire drills. All supervisory staff were educated and trained on the updated fire drill log on 5/2/25 and will begin implementing for the month of June `, 2025. The program director will review the fire drill log monthly for compliance and completeness. Results will be documented and discussed during monthly staff meetings. |
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 two records reviewed.
Client # 3 was admitted to the outpatient level of care on January 13, 2025 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 September 10, 2024, and expired on March 16, 2025; however, there was evidence of disclosures to the funding source after the release form expired.
Client # 5 was admitted to the outpatient level of care on August 13, 2024 and was discharged on November 18, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
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 5/16/25, specifically reviewing disclosure of information to be released. 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's ROI will be check and corrected, if necessary, by 6/15/25. |
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 seven of seven 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. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven client records, the facility failed to obtain consent to treatment during the intake procedures in three records reviewed.
Client # 3 was admitted on January 13, 2025 and was active at the time of the inspection.
Client # 6 was admitted on December 12, 2024 and was discharged on April 24, 2025.
Client # 7 was admitted on December 3, 2024 and was discharged on April 29, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/16/25, All intake staff were re-educated regarding the consent to treatment to be completed at the time of intake. Program director will complete monthly chart audits to ensure that the consent to treatment is completed in all client charts. An audit of active client charts will be conducted and any missing consents to treatment will be completed by 6/20/25. |
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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in six of seven applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed quarterly for the first year of treatment.
Client # 1 was admitted on December 17, 2024 and was active at the time of the inspection. The case consultation note was due to be completed by March 19, 2025; however, the note was not completed until March 21, 2025.
Client # 3 was admitted on January 13, 2025 and was active at the time of the inspection. The case consultation note was due to be completed by April 15, 2025; however, the record did not contain a case consultation note.
Client # 4 was admitted on June 19, 2024 and was discharged on December 24, 2024. The case consultation note was due to be completed by September 19, 2024; however, the note was not completed until October 9, 2024.
Client # 5 was admitted on August 13, 2024 and was discharged on November 18, 2024. The case consultation note was due to be completed by November 13, 2024; however, the record did not contain a case consultation note.
Client # 6 was admitted on December 12, 2024 and was discharged on April 24, 2025. The case consultation note was due to be completed by March 14, 2025; however, the note was not completed until April 8, 2025.
Client # 7 was admitted on December 3, 2024 and was discharged on April 29, 2025. The case consultation note was due to be completed by March 5, 2025; however, the record did not contain a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/23/25, all staff were retrained and educated regarding the policy of frequency of case consultations. The program director will be responsible for ensuring compliance through weekly supervision with staff members and monthly chart audits. |
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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within seven days of discharge, per facility policy, in two of four applicable records reviewed.
Client # 4 was admitted on June 19, 2024 and was discharged on December 24, 2024. The client record did not contain documentation of follow-up information.
Client # 5 was admitted on August 13, 2024 and was discharged on November 18, 2024. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were re-educated and trained on 5/23/25 regarding the follow-up policy, including the tracking document that is to be updated once a client discharges and the follow up is completed. The program director will complete monthly audits of discharges client charts to ensure that the follow up is being completed within 7 days of discharge. |