INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 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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709.28 (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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 6 was admitted on August 9, 2023, and was discharged on October 30, 2023. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site director educated staff on completing ROIs for all funding sources during staff meeting on 3/27/2024. During this education, director also provided education to staff that it is best practice to check ROIs in client charts when client is assigned to caseload, and also bi monthly on an ongoing basis. Education also included that prior to communicating with any outside entity clients charts for active ROIs are to be verified prior. Site director will conduct monthly chart audits during supervision with staff directly to ensure ongoing compliance. |
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 obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure in one of seven records reviewed.
Client # 3 was admitted on October 23, 2023, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated July 10, 2023, to a probation agency did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site director completed staff education on 3/27/2024 that included how to accurately ROIs in their entirety. Director specifically focused on dates of ROIs, and purpose. A mock fully completed ROI was used as reference and provided copies to the staff for ongoing reference. Chart audits will be completed on going during supervision to ensure that ROIs are being completed fully with all required information. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facilities policy and procedure manual and specifically the unusual incident policy, the facility failed to include the following unusual incident of an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regional Director reviewed current unusual incident policy along with DDAP regulation and made the appropriate changes to the organizations policy so that it accurately reflects the completion of a unusual incident form to DDAP when there are presence of police, fire and/or ambulance personnel on site. Staff were educated by Director on 4/1/2024 about the new policy and the changes that were made, and expectation of unusual incidents being report to DDAP when there is a presence of police, fire or ambulance personnel. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed have intake procedures that included the documentation of a psychosocial evaluation within seven days in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure was written by regional director on 3/28/2024 to include that psychosocial evaluations are to be completed and documented at the time of intake. The new policy and expectations of psycohocial evaluations being completed and documented at time of intake was reviewed with staff on 4/1/24. Director will conduct charts weekly on all new intakes to ensure that ongoing compliance occurs. |
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 develop individual treatment and rehabilitation plans with the client within thirty days of admission, per the policy manual, in two of six applicable records.
Client # 2 was admitted on November 21, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was due no later than December 21, 2023; however one was not documented until January 5, 2024.
Client # 6 was admitted on August 9, 2023, and was discharged on October 30, 2023. A treatment and rehabilitation plan was due no later than September 3, 2023; however one was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director conducted a staff meeting on 3/28/2024 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 on going compliance of treatment plan timeframes remain in compliance. |
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 review and update treatment and rehabilitation plans at least every 60 days in two of four applicable records.
Client # 2 was admitted on November 21, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 5, 2024. A treatment and rehabilitation plan update was due no later than March 5, 2024; however there was no documentation of a treatment plan update in the client record.
Client # 3 was admitted on October 23, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 2, 2024. A treatment and rehabilitation plan update was due no later than March 2, 2024; however there was no documentation of a treatment plan update until March 13, 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 3/28/2024 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 on going 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 provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a case consultation is to occur quarterly for the first year of services and then annually thereafter in four of four applicable records reviewed.
Client # 1 was admitted on October 16, 2023, and was still active at the time of the inspection. A case consultation was due to occur no later than January 16, 2024; however, there was no case consultation documented.
Client # 2 was admitted on November 21, 2023, and was still active at the time of the inspection. A case consultation was due to occur no later than February 21, 2024; however, there was no case consultation documented.
Client # 3 was admitted on October 23, 2023, and was still active at the time of the inspection. A case consultation was due to occur no later than January 23, 2024; however, there was no case consultation documented.
Client # 4 was admitted on November 8, 2023, and was still active at the time of the inspection. A case consultation was due to occur no later than February 8, 2024; however, there was no case consultation documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director submitted a ticket within new EMR to have case consultation form added as a clinical document within the EMR system. The form was added to the EMR system on 3/13/2024. Staff were provided education y the director on 3/22/2024 on how to locate the form in the new EMR system, how to complete it 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. |
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 have a complete client record on an individual which includes information relative to the client's involvement with the project including follow-up information within 7 days of discharge, per facility policy, in two of three applicable records.
Client # 6 was admitted on August 9, 2023, and was discharged on October 30, 2023. There was no follow-up information documented in the client record.
Client # 7 was admitted on September 25, 2023, and was discharged on November 7, 2023. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Director developed a protocol for admin staff, case management staff, and/or identified staff to conduct follow up outreach within 7 days of client discharge. Staff were educated about this process by director on 3/26/24. This will be documented in client's chart. Director will conduct ongoing chart audits to ensure compliance. |