INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 1, 2026 through April 2, 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's March 2025 through February 2026 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The facility's posted hours of operation are Monday through Friday 8:00AM - 8:00PM. All the fire drills conducted, during the reviewed period, were completed prior to or at 4:00PM. There were no fire drills conducted during the evening hours of operation. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility supervisor will designate one day per month to conduct a fire drill. Drills will be conducted on a rotating schedule, with one occurring during evening hours every other month and one during daytime hours on alternating months to ensure coverage across shifts. The on-site supervisor will ensure that drills are conducted when both staff and clients are present to promote effective participation and preparedness |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's March 2025 through February 2026 fire drill logs, the facility failed to set off the fire alarm or a smoke detector during each fire drill conducted during the reviewed period. At the time of the inspection, there was no documentation indicating a fire alarm or smoke detector was set off for the fire drill conducted in February 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/27/26, staff was educated on the proper protocol to ensure that during a fire drill, the fire alarm is set off to include the sound alarm to be audible throughout the building.
Program director will ensure compliance by reviewing the fire drill logs each month. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records and discussions with project staff, the project failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.The facility's policy and procedures stated all client records shall be maintained in a secure electronic medical record (EMR) system, and the policy applies to all client records created and maintained by the behavioral health providers and administrative staff, including clinical notes, assessments, treatment plans, progress notes, billing documentation and correspondence. At the time of the inspection, the facility does not keep paper client records and maintains an electronic record system. All paper documentation is to be scanned into the electronic record by the staff in a timely fashion. During the client record review, most of the client initial, comprehensive, and updated treatment plans were uploaded/linked to the electronic medical record within a few days of this inspection's start date. The treatment plans reviewed during the inspection were completed in 2025 and the staff were not following facility policy.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/23/2026, all staff have been retrained on the timely uploading of all paper documents into each client's electronic medical record. Training emphasized the importance of prompt documentation and reviewed required timeframes for uploading all records, with specific focus on treatment plans. Staff were re-educated that completed treatment plans must be uploaded to the client's EMR within 24 hours of completion.
To ensure ongoing compliance, the supervisor will conduct monthly chart audits to verify that the complete client record, including all paper documentation, is accurately uploaded and accessible within the client's electronic medical record. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the narcotic treatment program failed to verify an individual's identity, which includes the name, address, date of birth, emergency contact and other identifying data, prior to the administration of an agent in one of eight patient records reviewed. Patient #2 was admitted on August 12, 2025 and was active at the time of the inspection. There was no documentation of the patient's emergency contact in the record as of the date of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/15/26, during clinical staff meeting, all staff were re-educated on proper completion of releases of information and protocol if a patient declined to identify an emergency contact. If patient declines to identify an emergency contact, staff will document the patient's refusal on the release of information and a note to chart. Program director will ensure compliance via routine chart audits. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which includes the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in one of one applicable patient record reviewed. Patient #4 was admitted on December 31, 2024 and was discharged on October 29, 2025. At the time of the inspection, there was no documentation in the record indicating the receiving narcotic treatment program was notified and received patient files, including the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A transfer packet checklist has been implemented and is required to be completed prior to any client transfer. Responsibility for ensuring completion has been clearly assigned between nursing and clinical staff. Staff were retrained on 4/15/26 regarding transfer requirements including all required documentation elements and timelines. Program Director will ensure compliance via tracking system and will complete ongoing audits. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in two of three applicable patient records reviewed. Patient #2 was admitted on August 12, 2025 and was still active at the time of inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given at the time of the inspection. Patient #7 was admitted on July 15, 2025 and was discharged on December 18, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A standardized process has been implemented requiring verification of first and last dose for all transfers to and from inpatient settings. This includes use of a checklist and required documentation in the medical record prior to continuation of dosing. Responsibility for ensuring completion has been clearly assigned between nursing and clinical staff. Staff were trained on this process on 4/15/26. Program Director will ensure compliance via tracking system and will complete ongoing audits. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated, and signed by the medical director in two of two applicable patient records reviewed. Patient #3 was admitted on April 11, 2024 and was still active at the time of inspection. There was no documentation indicating the annual evaluation of the patient's status was completed as of the date of the inspection. Patient #6 was admitted on February 20, 2024 and was still active at the time of inspection. There was an annual evaluation of the patient's status, in the record, signed and dated by the medical director on March 16, 2026; however, the evaluation document was blank and incomplete. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A standardized tracking system has been implemented to monitor due dates for annual evaluations. An audit form was created to complete during routine supervisions with staff to ensure compliance of required documentation. Supervisors are responsible for reviewing and signing off on evaluations to ensure compliance and quality. All staff were trained and educated on this process on 4/15/26. Program director will ensure compliance via routine chart audits. |