INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2021 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that all counselors met the educational qualifications for the position in one of three applicable personnel records reviewed.
Employee #2, was hired as a counselor on September 11, 2020, met the experiential qualifications for the position of counselor; however at the time of hire, the employee had a Bachelor ' s Degree in Liberal Arts Studies, which is a non-qualifying degree for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director has changed Employee #2 status to a Counselor Assistant as of 6/28/2021. Employee #2 will now be supervised by a counselor and their notes will be signed off on to comply with counselor assistant requirements. Per site inspector's recommendation employee #2 will only need to receive supervision 1x a month due to their documented experience in the field.
Executive Director, or authorized designee, will be responsible for supervising counselor assistant.
Facility will also submit a DDAP exception to see if employee #2 may be authorized to be promoted to a counselor due to his past experience and current graduate studies in a qualifying degree program. If and until exception is granted employee #2 will remain a Counselor Assistant until requirements are met for promotion.
To ensure this deficiency does not occur in the future Executive Director, or authorized designee, will make sure the employee degree matches the regulations required to be a Counselor. Facility will do this by comparing the regulation with the employee's credentials. If there is a question regarding this status Executive Director, or authorized designee, will contact DDAP for further clarification to ensure this deficiency does not occur again. |
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 September 2020 through June 2021 fire drill logs, the facility failed to conduct fire drills at different times of the day and night and on different staffing shifts. Every monthly drill that was done during the workweek was conducted at 12:30pm or earlier; however, the facility's hours of operation are Monday-Friday from 8:00am to 8:00pm and Saturday and Sunday from 8:00am to 2:00pm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting with July 2021 Fire Drill; Facility will conduct monthly fire drills at different days of the week, different times of the day, and different shifts at the facility to represent fire drills during various hours of facility operation. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a dated signature of a witness on a release of information form in one of seven client records reviewed.
Client #6 was admitted into the outpatient level of care on October 9, 2020 and was discharged on December 3, 2020. There was a release of information form to a physician that was signed and dated by the client on October 9, 2020; however, the release form did not document a dated signature of a witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review the procedure for navigating the electronic chart system within the facility for capturing client and staff signatures on all consents and release of information forms during July supervision with staff.
To prevent this deficiency from occurring again Executive Director will have the administrative team conduct monthly chart audits ensuring that documentation is completed, signed, and dated correctly. These audits will be logged and reviewed by Executive Director or authorized designee. |
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 maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #4 was admitted on December 28, 2020 and was discharged on April 22, 2021. There was no post-discharge follow-up information in the client record at the time of the inspection.
Client #5 was admitted on October 9, 2020 and was discharged on April 22, 2021. There was no post-discharge follow-up information in the client record at the time of the inspection.
Client #7 was admitted on March 19, 2021 and was discharged on May 20, 2021. There was no post-discharge follow-up information in the client 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
Executive Director, or authorized designee, will ensure that all discharge follow-up letters completed from 06/28/2021 on will be completed at least one day after the completion of the discharge summary and not on the actual date of the discharge summary. Discharge follow up letters will need to be completed within 7 days of the discharge summary but not on the date of the completed discharge summary.
To ensure this deficiency does not occur in the future Executive Director will have the administrative team conduct monthly audits and documenting that the discharge letter has been completed and that the date occurred after the discharge summary. These audits will be logged and reviewed by Executive Director or authorized designee. |