INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2024 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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709.25 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.The project had an exception to the regulation requiring an audit if the project's gross income is less than $500,000. However, the project provided a copy of their 2022 tax return indicating that the gross income exceeded $500,000 for the project's previous fiscal year; therefore, the exception is no longer valid, and a financial audit must be completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
MVP Recovery has obtained the services of a public independent certified account for ongoing accounting services effective 5/1/2024. MVP Recovery has obtained the accounting firm and our CEO has signed a contract with this company to conduct our annual financial audits. The audit is expected to be completed by 7/1/2024. The contract will be a maintained contract ongoing for compliance which will be overseen by the CEO. |
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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in four of fourteen client records reviewed.Client # 5 was admitted to the partial hospitalization activity on October 12, 2023 and was discharged on October 30, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 7 was admitted to the partial hospitalization activity on December 4, 2023 and was discharged on December 8, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 9 was admitted to the outpatient activity on November 1, 2023 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 11 was admitted to the outpatient activity on October 23, 2023 and was discharged on December 4, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/21 Site director held a staff meeting and provided staff education around the policy and procedures of Releases of Information and the confidentiality standards and regulations. It was specifically reviewed that prior to releasing any information to any entity including a funding source, the staff member is to check the ROI section of the client's chart to ensure that there is a fully completed, signed and active ROI for said entity that is needing to be communicated with. It was also reviewed in the policy that if a funding source and/or any other entity is requiring communication regarding any needs of the clients treatment and there is no signed ROI in the chart for said entity then the staff member is to have the client complete an ROI prior to releasing or communicating with an entity. Site director will monitor this by spot checking charts in supervision and independently and will have supervision conversations around confidentiality and ROIs for ongoing compliance. Client #9 counselor was informed on 5/21 to have the ROI completed for clients funding source, clients appointment is next scheduled for 5/24 and will be completed at that appointment. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment and rehabilitation plans in two of two applicable client records reviewed.Client # 4 was admitted to the partial hospitalization activity on November 6, 2023 and was discharged on December 5, 2023. The individual treatment and rehabilitation plan was completed on November 20, 2023; however, there was no type and frequency of treatment services documented on the plan.Client # 6 was admitted to the partial hospitalization activity on December 21, 2023 and was discharged on January 8, 2024. The individual treatment and rehabilitation plan was completed on December 27, 2023; however, there was no type and frequency of treatment services documented on the plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/21 site director met with staff to review and provide education on the requirements of initial treatment plans. It was specifically reviewed that staff are to include the type, i.e. group/individual along with level of care and frequency of treatment that client is to be attending on clients treatment plans. Site director will conduct audits in supervision and independently to ensure ongoing compliance. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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 the proposed type of support services on individual treatment and rehabilitation plans in two of two applicable client records reviewed.Client # 4 was admitted to the partial hospitalization activity on November 6, 2023 and was discharged on December 5, 2023. The individual treatment and rehabilitation plan was completed on November 20, 2023; however, there were no proposed type of support services documented on the plan. Client # 6 was admitted to the partial hospitalization activity on December 21, 2023 and was discharged on January 8, 2024. The individual treatment and rehabilitation plan was completed on December 27, 2023; however, there were no proposed type of support services documented on the plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/21 site director met with staff to review and provide education on the requirements of initial treatment plans. It was specifically reviewed that staff are to include the type of support services offered to the client on each treatment plan. Site director will conduct audits in supervision and independently to ensure ongoing compliance. |
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 four of six applicable client records reviewed. Client # 9 was admitted to the outpatient activity on November 1, 2023 and was still 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 # 11 was admitted to the outpatient activity on October 23, 2023 and was discharged on December 4, 2023. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection. Client # 12 was admitted to the outpatient activity on January 22, 2024 and was discharged on March 7, 2024. There was no documentation of a preliminary treatment and rehabilitation plan in the record at the time of the inspection. Client # 13 was admitted to the outpatient activity on December 19, 2023 and was discharged on March 4, 2024. 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
Site director met with staff on 5/21/2024 to review the requirements of completing the preliminary treatment plans as a part of the intake process paperwork. Site director will spot check all new intakes weekly to ensure that the preliminary treatment plans are being completed at the time of intake for ongoing compliance. |
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, the facility failed to ensure individual treatment and rehabilitation plans were completed and developed with the client in four of seven applicable client records reviewed. Client # 9 was admitted to the outpatient activity on November 1, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than December 1, 2023; however, the individual treatment and rehabilitation plan was completed on December 5, 2023.Client # 11 was admitted to the outpatient activity on October 23, 2023 and was discharged on December 4, 2023. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.Client # 13 was admitted to the outpatient activity on December 19, 2023 and was discharged on March 4, 2024. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.Client # 14 was admitted to the outpatient activity on December 14, 2023 and was discharged on March 20, 2024. The individual treatment and rehabilitation plan was due to be completed no later than January 14, 2024; however, the individual treatment and rehabilitation plan was completed on February 5, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/21/2024 site director met with staff during staff meeting to provide education and review of treatment planning and the time frames that treatment plans are required to be completed within. It was specifically reviewed with all staff that the initial treatment plan is to be completed within the first 30 days of admission to the program and the updated treatment plans are to be done every 60 days thereafter. Site director will conduct chart audits in supervision and independently to ensure ongoing compliance. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in one of three applicable client records reviewed. Client # 8 was admitted to the outpatient activity on December 6, 2023 and was still active at the time of the inspection. A treatment plan update was completed on February 7, 2024 and the next update was due no later than April 7, 2024; however, the update was completed on April 23, 2024. This is a repeat citation from the May 16, 2022 and May 23, 2023 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/21/2024 site director met with staff during staff meeting to provide education and review of treatment planning and the time frames that treatment plans are required to be completed within. It was specifically reviewed with all staff that the initial treatment plan is to be completed within the first 30 days of admission to the program and the updated treatment plans are to be done every 60 days thereafter. Site director will conduct chart audits in supervision and independently to ensure ongoing compliance. |
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 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 May 7, 2024, licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Regional Director met with all supervisors on 5/22/24 to review the requirements of ensuring that supervision is done and that chart audits are conducted weekly to ensure that treatment plans are done and updated in accordance with the timeframes and that the plan of correction is followed. ON 5/22/24 a treatment plan tracking sheet was developed to track all active clients effective 6/1/24, that will include clients name, date of admission, preliminary treatment plan completed and date, date that initial tx plan is due and dates of ongoing treatment plan updates.
This tracking sheet will be kept by each site director and will be reviewed in the weekly team meeting every Friday for ongoing compliance. Regional director will review every Friday as well to ensure ongoing compliance. |