INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2023 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) (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 client records, the facility failed to document the dated signature of a client on release of information forms in one of seven client records reviewed.
Client #3 was transferred to this facility from another location within the project on August 2, 2023 and was active at the time of inspection. Release of information forms to an emergency contact, a funding source, and a primary care physician were signed and dated by the witness on May 30, 2023, but the dated signature of the client was not included on any of the release forms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During staff meeting on 9/15/2023 director will provide education on Confidentially and specifically on completing ROIs fully and to ensure all information is completed by staff member and client at the time of the appointment. Staff will be educated to review all signatures and dates by clients when completing ROIs with clients to ensure that the document is completed in its entirety. Director will conduct chart audits of 5 charts per week for the next 3 months to ensure all ROIs are completed to include signatures and dates. For the chart that was identified during the inspection, that specific staff member was addressed regarding the concern specifically and was provided one on one education about the issues with this ROI. Staff member was then addressed to complete and new ROI with client. The ROI was completed and submited to supervisor for review. |
709.34 (a) (7) 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:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to include in their unusual incident policies and procedures, a specific policy and procedure on how to respond to a fire or structural damage to the facility.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with DDAP regulation 709.34, director has rewritten Unusual incident policy to include a procedure on how to respond to a fire or structural damage to the facility. The policy now includes that if there is fire or structural damage to the facility, staff and employees will follow the evacuation plan that is also practiced monthly at the time of the fire. 911 will be called immediately. Once staff members account for all of their clients (if clients are present during the time of the event), and director or designated staff will locate all staff members that will be documented on evacuation form. In the need to ensure that staff and clients are present and accounted for, director will wait for Fire Department to give clearance to return to the building or not. In the event that building is safe to return to, staff will debrife the event with clients, and director will debrif with staff later that same day. this will all be documented and an unusal incident will be completed. In the event that there is damaage and the building is unable to be returned to, staff will ensure all contact information for clients present is accurate and will send clients home for the day. Organization will arrange for transportation if needed for any staff/clients needed. If the damage to the building makes the building unsafe to return to. Director and staff members will work together from another MVP treatment location, to offer telehealth support, and will also work to transfer clients to another MVP treatment location to continue with their services or another local provider, which ever is best for the clients needs. This plan and incident report form will be sent to all appropriate oversight entities by director. Staff will be educated on this in team meeting on 9/19/23. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the project's policy and procedure manual, the project failed include in their unusual incident policies and procedures, a specific policy and procedure on the reporting mechanism used to ensure that the reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director has rewritten organizations policy regarding reporting of unusual incidents. This policy has been corrected to reflect specifically the mechanism of reporting to ensure is in compliance with guidelines. Any unusual incident will be completed by the staff member that witnessed it and/or it was told to. That staff member will bring that to direct supervisor /to then review and ensure all information is reported in an objective and accurate manner. Director will review and will pull all reporting documents for appropriate state, federal and county entities. Director and staff member will complete the form with only necessary information required. Director will then ensure that the incident form is submitted through a secure and confident manner in alignment with confidentiality guidelines. Staff will review this new policy in team meeting on 9/19/23 and will sign off on the education. Director will also have this policy in new hire orientation. |
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 are reviewed and updated at least every 60 days in three of four applicable client records reviewed.
Client #1 was transferred to this facility from another location within the project on July 26, 2023 and was active at the time of inspection. A treatment plan update was completed at the prior facility on June 6, 2023 and the next update was due no later than August 6, 2023; however, the update was not completed until August 15, 2023.
Client #2 was transferred to this facility from another location within the project on July 31, 2023 and was active at the time of inspection. A treatment plan update was completed at the prior facility on June 8, 2023 and the next update was due no later than August 8, 2023; however, the update was not completed at the time of inspection.
Client #3 was transferred to this facility from another location within the project on August 2, 2023 and was active at the time of inspection. A treatment plan update was completed at the prior facility on June 1, 2023 and the next update was due no later than August 1, 2023; however, the update was not completed until August 23, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During staff meeting on 9/15/23 director will review treatment plan policy with all staff completing treatment plans. Director will review specific time frames of treatment plan updates due within 60days of last treatment plan. Director will review ways to track these time frames with staff like setting calendar reminders and using excel spreadsheets. Director will also review treatment plan status for all clients during individual staff supervision weekly. Director will conduct chart audits to monitor compliance. |