INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 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indicating that the gross income exceeded $500,000 for the project's previous fiscal year; therefore, the exception is no longer valid, and a financial audit must be completed.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. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client records reviewed.
Client # 5 was admitted to the outpatient activity on March 18, 2024 and was administratively discharged on April 10, 2024. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Site director conducted a staff education on the policy and procedure of involuntary termination of client services during a staff meeting on 5/23/2024. It was specifically reviewed that when an involuntary discharge is being conducted, that the client is to be notified of discharge in writing which includes the reason for discharge. Site director will conduct reviews of all discharges to ensure that notification in writing is given for any involuntary discharges of clients from services to monitor ongoing compliance.
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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 five of five applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on December 29, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 8, 2024 and an update was due no later than March 8, 2024; however, the update was completed on March 18, 2024.
Client # 2 was admitted to the outpatient activity on December 15, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 8, 2024 and an update was due no later than March 8, 2024; however, the update was completed on March 18, 2024.
Client # 3 was admitted to the outpatient activity on December 18, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 8, 2024 and an update was due no later than March 8, 2024; however, the update was completed on March 12, 2024.
Client # 4 was admitted to the outpatient activity on November 2, 2023 and was discharged on April 29, 2024. A treatment plan update was completed on February 14, 2024 and another update was due no later than April 14, 2024; however, the update was not completed prior to discharge.
Client # 6 was admitted to the outpatient activity on December 11, 2023 and was discharged on April 22, 2024. The individual treatment and rehabilitation plan was completed on February 2, 2024 and an update was due no later than April 2, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director conducted a staff meeting on 5/23/2024 to review the policy of treatment plans and updated treatment plans for all staff. Chart audits will be conducted both in supervision with staff and independently by director to ensure ongoing compliance of treatment plan timeframes remain in compliance. |
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, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in three of five applicable client records reviewed.
Client # 3 was admitted to the outpatient activity on December 18, 2023 and was still active at the time of the inspection. There were no case consultation notes documented in the record as of the date of the inspection.
Client # 4 was admitted to the outpatient activity on November 2, 2023 and was discharged on April 29, 2024. There were no case consultation notes documented in the record at the time of the inspection.
Client # 6 was admitted to the outpatient activity on December 11, 2023 and was discharged on April 22, 2024. There were no case consultation notes documented in the record at that time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were provided education by the director on 5/23/2024
on how to complete the case consultation in its entirety, and that the case consult
forms are to be completed at Level of
Care changes, and for any
behavioral concerns for every client.
Director will conduct chart audits to
ensure on going compliance. All active clients will have case consultations completed by 6/15/24.
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