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 22, 2024 through April 23, 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indicating that the gross income exceeded $500,000 for the project's previous fiscal year; therefore, the exception is no longer valid and a financial audit must be completed.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 public account for ongoing accountings services effective 5/1/2024. MVP Recovery has obtained the service's of an independent accounting firm and our CEO has signed a contract with this company to conduct our annual financial audits. This will be a maintained contract ongoing for compliance which will be overseen by the CEO. The audit is expected to be completed by 7/1/2024 |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in one of seven applicable client records reviewed. Client # 1 was admitted to the outpatient maintenance activity on December 19, 2023. There was a blank release of information form, signed by the client on December 19, 2023, that did not include the name of the person, agency, or organization to whom the disclosure would be made to. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/2024 site director conducted a departmental staff meeting to review the policy and procedure of completing Releases of Information to ensure that all required information is completed and signed off on for the Release of information to be valid. It was specifically reviewed in this meeting that the documented entity is required at the time of client and staff signing release of information or the release is considered invalid. Site director will conduct ongoing chart audits weekly in supervision with staff and independently to ensure that ongoing compliance occurs. |
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 client records, the facility failed to document the specific information to be released on a consent to release information form in one of seven applicable client records reviewed. Client # 1 was admitted to the outpatient maintenance activity on December 19, 2023. There was a blank release of information form, signed by the client on December 19, 2023, that did not include the specific information to be released.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/2024 site director conducted a departmental staff meeting to review the policy and procedure of completing Releases of Information to ensure that all required information is completed and signed off on for the Release of information to be valid. It was specifically reviewed in this meeting that the release of information must include what specific information will be released to identified entity on the document which is required to be completed with client at the time of client and staff signing release of information or the release is considered invalid. Site director will conduct ongoing chart audits weekly in supervision with staff and independently to ensure that ongoing compliance occurs. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven applicable client records reviewed. Client # 1 was admitted to the outpatient maintenance activity on December 19, 2023. There was a blank release of information form, signed by the client on December 19, 2023, that did not include the purpose of the disclosure.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/2024 site director conducted a departmental staff meeting to review the policy and procedure of completing Releases of Information to ensure that all required information is completed and signed off on for the Release of information to be valid. It was specifically reviewed in this meeting that the purpose of the disclosure to the identified entity is required at the time of client and staff signing release of information or the release is considered invalid. Site director will conduct ongoing chart audits weekly in supervision with staff and independently to ensure that ongoing compliance occurs. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on consent to release information forms in one of seven applicable client records reviewed. Client # 1 was admitted to the outpatient maintenance activity on December 19, 2023. There was a blank release of information form, signed by the client on December 19, 2023, that did not include the date, event, or condition upon which the consent will expire. Additionally, there was a release of information form to a government agency, signed by the client on December 19, 2023, that did not include the date, event, or condition upon which the consent will expire.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/2024 site director conducted a departmental staff meeting to review the policy and procedure of completing Releases of Information to ensure that all required information is completed and signed off on for the Release of information to be valid. It was specifically reviewed in this meeting that the effective and expiration date is required to be written at the time of client and staff signing release of information or the release is considered invalid. Site director will conduct ongoing chart audits weekly in supervision with staff and independently to ensure that ongoing compliance occurs. |
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 verify the individual's identity including the name, address, and date of birth prior to the administration of an agent in one of seven applicable patient records reviewed. Client # 5 was admitted to the outpatient maintenance activity on January 17, 2024 and was discharged on April 16, 2024. There was no documentation that the verification of the patient's identity was completed in the patient record prior to the administration of an agent. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed intake policy and educated staff to ensure compliance with 715.9 (a)(2) regarding screening and identity verification during staff meeting on 4/30/2024. The Program Director reviewed that MVP Recovery staff will collect photo IDs and identifying information on all individuals upon intake. The photo ID will be scanned into the clients EMR Chart and all other pertinent information will be entered into the system immediately. All staff were educated that prior to administration of an agent individuals identify must be verified. Program Director will conduct weekly chart audits on all new intakes to ensure ongoing compliance. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent, with all required components, before an agent may be administered to the patient for either maintenance or detoxification treatment in five of seven applicable patient records reviewed. Client # 1 was admitted to the outpatient maintenance activity on December 19, 2023 and was still active at the time of the inspection. The informed consent form was signed by the patient on January 24, 2024, but the form did not include that methadone is a narcotic drug which can be harmful if taken without medical supervision, that methadone is an addictive medication, and that methadone is transmitted to the unborn child and will cause physical dependence.Client # 2 was admitted to the outpatient maintenance activity on January 16, 2024 and was still active at the time of the inspection. The informed consent was signed by the patient on January 17, 2024, but the form did not include that methadone is a narcotic drug which can be harmful if taken without medical supervision, that methadone is an addictive medication, and that methadone is transmitted to the unborn child and will cause physical dependence.Client # 5 was admitted to the outpatient maintenance activity on January 17, 2024 and was discharged on April 16, 2024. The informed consent was signed by the patient on January 16, 2024, but the form did not include that methadone is a narcotic drug which can be harmful if taken without medical supervision, that methadone is an addictive medication, and that methadone is transmitted to the unborn child and will cause physical dependence.Client # 6 was admitted to the outpatient maintenance activity on January 30, 2024 and was discharged on April 5, 2024. The informed consent was signed by the patient on January 16, 2024, but the form did not include that methadone is a narcotic drug which can be harmful if taken without medical supervision, that methadone is an addictive medication, and that methadone is transmitted to the unborn child and will cause physical dependence.Client # 7 was admitted to the outpatient maintenance activity on January 25, 2024 and was discharged on March 11, 2024. The informed consent was signed by the patient on January 25, 2024, but the form did not include that methadone is a narcotic drug which can be harmful if taken without medical supervision, that methadone is an addictive medication, and that methadone is transmitted to the unborn child and will cause physical dependence.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director created a new informed patient consent form that includes the following information but the form did not include that methadone is a narcotic drug which can be harmful if taken without medical supervision, that methadone is an addictive medication, and that methadone is transmitted to the unborn child and will cause physical dependence.
Program director reviewed and educated staff on the new consent form to be used and what specific added information the consent included to make the form compliant, during staff meeting on 4/30/2024. Site director deleted old consent form from EMR on 4/29/2024 and new form was effective in new EMR on 4/30/2024. Program director also met with Nursing director to conduct a chart audit on 4/30/2024 and identified all clients that needed to have new consents signed. on 4/30/2024 all clients that needed an updated consent signed, were flagged in the EMR for dosing and all new consents were completed on 5/6/2024. Program Director will conduct weekly chart audits on all new intakes to ensure 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 developed and completed with the client timely, in five of thirteen applicable client records reviewed. Client # 3 was admitted to the outpatient maintenance activity on January 24, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than February 24, 2024; however, the plan was not completed until March 15, 2024. Client # 6 was admitted to the outpatient maintenance activity on January 30, 2024 and was discharged on April 5, 2024. The individual treatment and rehabilitation plan was due to be completed no later than February 29, 2024; however, the plan was not completed prior to discharge. Client # 7 was admitted to the outpatient maintenance activity on January 25, 2024 and was discharged on March 11, 2024. The individual treatment and rehabilitation plan was due to be completed no later than February 25, 2024; however, the plan was not completed prior to discharge. Client # 8 was admitted to the outpatient activity on February 26, 2024 and was discharged on April 2, 2024. The individual treatment and rehabilitation plan was due to be completed no later than March 26, 2024; however, the plan was not completed prior to discharge. Client # 9 was admitted to the outpatient activity on December 28, 2023 and was discharged on March 11, 2024. The individual treatment and rehabilitation plan was due to be completed no later than January 28, 2024; however, the plan was not completed until February 5, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director conducted a staff meeting on 5/9/2024 to review the policy of treatment plans and updated treatment plans for all staff. Specific time frames of initial treatment plan within 30 days and update treatment plans completed every 60 days was reviewed. Director will conduct chart audits in weekly supervision and independently to ensure compliance with treatment plan policy and procedure's. |
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 three of seven applicable client records reviewed. Client # 1 was admitted to the outpatient maintenance activity on December 19, 2023 and was still active at the time of the inspection. The individual treatment plan was completed on January 18, 2024 and an update was due no later than March 18, 2024; however, the update was not completed until April 5, 2024. Client # 2 was admitted to the outpatient maintenance activity on January 16, 2024 and was still active at the time of the inspection. The individual treatment plan was completed on February 7, 2024 and an update was due no later than April 7, 2024; however, the update was not completed until April 19, 2024. Client # 14 was admitted to the outpatient activity on November 3, 2023 and was still active at the time of the inspection. A treatment plan update was completed on November 9, 2023 and another update was due no later than January 9, 2024; however, the update was not completed until January 31, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director conducted a staff meeting on 5/9/2024 to review the policy of treatment plans and updated treatment plans for all staff. Specific time frames of initial treatment plan within 30 days and update treatment plans completed every 60 days was reviewed. Director will conduct chart audits in weekly supervision and independently to ensure compliance with treatment plan policy and procedure's. |