INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on May 1, 2025 through May 2, 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 director 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. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee # 2 was hired as a clinical supervisor on June 26, 2023 and has remained in that position. Employee # 2 was reported to have 35 hours per week devoted to the 40 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the staff member ' s ratio, the total number of clients on their caseload is divided by the FTE.
The FTE caseload calculation is as follows: 35/40 = 0.87 (FTE); 40/0.87= 45.9, which equals to a client/counselor ratio of 45:1.
The overall facility FTE follows the above equation. The facility was reported to have 75 hours per week devoted to their 75 clients.
The facility FTE caseload calculation is as follows: 75/40=1.8 (FTE); 75/1.8= 41.6, which equals to a client/counselor ration of 41:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to the citation under §704.12(a)(6), Program Director has taken immediate action to ensure that counselor caseloads in the outpatient program do not exceed the regulatory limit of 35 active clients per full-time equivalent (FTE) counselor. A thorough review of current caseloads was completed, and it was determined that staffing adjustments were necessary to achieve and maintain compliance. As part of the corrective action, MVP Recovery has initiated the hiring process for an additional qualified counseling staff member to help offset the current caseload distribution and ensure that all counselors remain within the required FTE ratio. The Program Director will oversee this hiring process and will also implement monthly caseload audits to monitor compliance moving forward. These corrective actions were initiated on 5/21/2025 full compliance anticipated by 6/21/2025. |
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 April 23, 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 eight 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 # 8 was admitted on July 25, 2024 and was discharged on February 5, 2025. The record contained documentation of a disclosure of information to another treatment provider on July 25, 2024, however, the record did not contain a client signed consent to release information form to the treatment provider.
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 5/20/25 regarding the requirement to complete a release of information for any source communicated with. Any missing releases of information that are missing from the chart will be completed by 6/13/25. All current client charts were audited to ensure that there are appropriate releases of information in all charts. The program director will complete monthly chart audits and review that all releases of information are present in the client chart. |
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 eight client records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client # 5 was admitted on May 28, 2024 and was discharged on June 11, 2024. A consent to release information form to another treatment provider was signed and dated by the client on May 28, 2024, that was missing documentation of the specific information to be disclosed.
This is a repeat citation from the April 23, 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 5/20/25, 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. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of eight client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client # 6 was admitted on December 5, 2024 and was active at the time of the inspection. The record contained six consent to release information forms to various individuals and agencies dated December 5, 2024 by the witness, that were signed by the client; however, the signature did not include a date.
The 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 5/20/25, specifically reviewing that the release is signed and dated by the client. Weekly chart audits will be performed by program director and staff member during clinical supervision. Releases of information will be checked during chart audits, specifically checking that the client's signature and date is completed in its entirety. Releases of information will be checked by every clinician prior to releasing information to any source. All releases for active clients will be reviewed and updated as necessary by 6/20/25. |
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 six of six applicable records reviewed.
Client #1 was admitted on November 12, 2024 and was still an active client at the time if the inspection.
Client #2 was admitted on September 27, 2024 and was still an active client at the time of the inspection.
Client #4 was admitted on May 14, 2024 and was discharged April 30, 2025.
Client #5 was admitted on May 28, 2024 and discharged on June 11, 2024.
Client #6 was admitted on December 5, 2024 and was still an active client at the time of the inspection.
Client #8 was admitted on July 25, 2024 and was discharged of February 5, 2025.
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 5/20/25 and will be implemented at each intake appointment beginning on 5/26/25. Program director 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. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review 17 weeks of physician and certified registered nurse practitioner time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for one week reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of December 29, 2024 through January 4, 2025, the patient census was 66. The physician was required to provide one-third of the 6.6 hours, which equals to 2.1 hours. The physician provided 0 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to the citation under §715.6(e) regarding physician staffing requirements in the narcotic treatment program, MVP Recovery has taken immediate corrective action to ensure compliance with federal and state regulations. On 5/20/25, the requirements for physician staffing was reviewed with the medical director and medical staff. The Program Director and Medical Director will jointly monitor scheduling and time logs to ensure the required physician ratio is consistently maintained. A formal tracking system has also been established to document physician, PA, and CRNP hours to ensure ongoing compliance. Ongoing oversight will be conducted monthly to prevent future discrepancies. |
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 facility failed to ensure that verification of the individual's identity was obtained during the intake process in two of six applicable records reviewed.
Patient # 2 was admitted on September 27, 2024 and was active at the time of the inspection. The record did not contain documentation that the individual's identity was verified during intake.
Patient # 8 was admitted on July 25, 2024 and was discharged on February 5, 2025. The record did not contain documentation that the individual's identity was verified during intake.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/20/25, the program has instituted a standardized identity verification process to be completed during intake and prior to the first dose. This process includes confirming and documenting the individual's full name, date of birth, current address, emergency contact, and other identifying data, such as a government-issued ID. A standardized verification checklist has been developed and is now a required part of the intake process. This checklist will be completed by admissions staff and uploaded directly into each individual's electronic medical record (EMR) for documentation and compliance tracking. All admissions staff have been trained on 5/20/25 the new process, and the Clinical Director will oversee periodic audits to ensure ongoing adherence. |
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 the review of patient records, the facility failed to document a completed annual evaluation signed by the medical director in two of two applicable records.
Patient # 3 was admitted on April 16, 2024 and was active at the time of the inspection. The record did not contain an annual evaluation.
Patient # 7 was admitted on March 5, 2024 and was active at the time of the inspection. The record did not contain an annual evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/20/25, all staff were re-educated and trained regarding the requirements of an annual evaluation for all clients in the NTP program. The program director will be responsible for ensuring compliance of annual evaluation through weekly supervision with clinical staff and ongoing monthly chart audits. An audit will be completed of all active client charts who have been in services over a year and any missing evaluations will be completed by 6/20/2025. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of the unusual incident logbook and patient records, the project failed to file a written unusual incident report with the Department within 48 hours following an unusual incident involving the physical or sexual assault by staff or a client.
There was documentation of a patient assault on July 8, 2024; however, there was no documentation that a written unusual incident report was ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 5/20/25, all staff were re-educated and trained regarding the reporting of unusual incidents and the appropriate procedures to follow during and after unusual incidents. The program director will be responsible for ensuring the unusual incident reporting is completed within 48 hours of the unusual incident. The Executive director will complete ongoing monitoring of reporting procedures through monthly supervision with the program director. The incident report identified will be submitted to the Department by 6/6/25. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation included a familiarization with the fee schedule in four of six applicable records reviewed.
Client # 1 was admitted on November 12, 2024 and was active at the time of the inspection.
Client # 2 was admitted on September 27, 2024 and was active at the time of the inspection.
Client # 4 was admitted on May 14, 2024 and was discharged on April 30, 2025.
Client # 5 was admitted on May 28, 2024 and was discharged on June 11, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fee scheduled was added to the intake process on 1/13/25 and is reviewed with the client at the time of intake. All active clients who were admitted before 1/13/25, will review and document knowledge of the fee schedule with their primary counselor by 6/30/25. |
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 three of seven applicable records reviewed.
Client # 2 was admitted on September 27, 2024 and was active at the time of the inspection. A treatment plan update was completed on December 14, 2024 and the next treatment plan update was due to be completed by February 12, 2025; however, the treatment plan update was not completed until February 25, 2025.
Client # 3 was admitted on April 16, 2024 and was active at the time of the inspection. A treatment plan update was completed on July 5, 2024, and the next treatment plan update was due to be completed by September 3, 2025; however, the treatment plan update was not completed until September 11, 2024. A treatment plan update was completed on January 3, 2025, and the next update was due to be completed by March 4, 2025; however, the update was not completed until March 7, 2025.
Client # 7 was admitted on March 5, 2024 and was active at the time of the inspection. A treatment plan update was completed on August 16, 2024, and the next treatment plan update was due to be completed by October 15, 2024; however, the treatment plan update was not completed until October 25, 2024. A treatment plan update was completed on December 24, 2024, and the next update was due to be completed by February 22, 2025; however, no additional treatment plan updates were completed prior to the date of the inspection.
This is a repeat citation from the April 23, 2024 and August 24, 2023 annual licensing renewal inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Treatment plan requirements and due dates were reviewed with all staff during a meeting on 5/20/25. All staff acknowledged understanding of the timeline for treatment plans. The program director will be responsible for ongoing monitoring of compliance through weekly chart audits. Any late entries will be addressed with specific staff members during individual supervision. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of seven applicable records reviewed.
Client # 1 was admitted on November 12, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on January 7, 2025, indicated that the client was to receive two individual counseling sessions per month and two group sessions per week; however, no individual or group sessions were documented for the month of February 2025 and only one group and one individual session were documented for the month of January 2025.
Client # 2 was admitted on September 27, 2024 and was active at the time of the inspection. Treatment plans completed on December 14, 2024, and February 25, 2025, indicated that the client was to receive one individual counseling session per week. Only two individual sessions were documented for the months of December 2024 and January 2025, and only one session was documented for the month of February 2025.
Client # 3 was admitted on April 16, 2024 and was active at the time of the inspection. The treatment plan update completed on January 3, 2025, indicated that the client was to receive biweekly counseling sessions; however, the record only contained documentation of one counseling session for the month of February 2025.
Client # 7 was admitted on March 5, 2024 and was active at the time of the inspection. The treatment plan update completed on August 16, 2024, and October 25, 2024, indicated that the client was to receive twice weekly counseling sessions; however, the record only contained documentation of three counseling sessions for the month of October 2024 and four counseling sessions for the month of September 2024.
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 5/20/25 regarding the expectation of frequency of treatment services and the appropriate documentation to be completed if there are missed treatment sessions. The program director will be responsible for ensuring compliance of treatment services and documentation through weekly staff supervision and chart audits. |
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 five of seven applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed quarterly for the first year of treatment, and annually thereafter.
Client # 2 was admitted on September 27, 2024 and was active at the time of the inspection. The first case consultation note was completed on December 27, 2024. The second case consultation was due to be completed by March 27, 2025; however, the next case consultation was not documented until April 4, 2025.
Client # 3 was admitted on April 16, 2024 and was active at the time of the inspection. The third case consultation note was completed on January 10, 2025, and the fourth case consultation note was due to be documented by April 16, 2025; however, no additional case consultation notes were documented prior to the date of the inspection.
Client # 4 was admitted on May 14, 2024 and was discharged on April 30, 2025. The first case consultation note was due to be documented by August 14, 2024; however, the case consultation note was not documented until August 16, 2024.
Client # 6 was admitted on December 5, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by March 5, 2025; however, the case consultation note was not documented until April 4, 2025.
Client # 7 was admitted on March 5, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by June 5, 2024; however, the case consultation note was not documented until June 11, 2024. The next case consultation note was due to be completed by September 5, 2024; however, it was not documented until September 17, 2024. The fourth case consultation note was due to be completed by March 5, 2025; however, it was not documented until April 4, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/20/25, 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. |
709.17(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 April 23, 2024, and August 24, 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 1, 2025 through May 2, 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. |