INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 25, 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:
|
Plan of Correction
|
704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
|
Observations
Based on a review of six personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.
Employee # 2 was promoted to the position of clinical supervisor on June 1, 2024 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree, but only one year of clinical experience, not the required minimum of three years.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The current clinical supervisor has obtained their master's degree on 5/18/25 and currently meets the qualifications of clinical supervisor. All management staff were retrained on the qualifications of clinical supervisor on 5/15/25 during a staff meeting. Moving forward, the Executive Director is responsible for ensuring that all new hires or promoted staff meet the qualifications of their perspective roles. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of six personnel files, the facility failed to ensure that one applicable clinical supervisor who had not functioned for 2 years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision.
Employee # 2 was promoted to the position of clinical supervisor on June 1, 2024 and is current in that position. Employee # 2 did not function for 2 years as a supervisor and has not completed a core curriculum as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The current Clinical supervisor will obtain required training by June 16th.
The management staff were retrained on the appropriate trainings required for all staff on 5/8/25 during a staff meeting. The Executive Director will ensure all required training for supervisors are properly given to staff and obtained within a timely matter. |
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.
|
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.
|
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 team 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. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of six personnel records, the facility failed to ensure that one applicable employee received a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum within the regulatory timeframe.
Employee # 4 has been in the position of counselor since February 5, 2024 and was due to have the communicable disease trainings no later than February 5, 2025; however, the HIV/AIDS training was not completed as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #4 will complete the HIV/AIDS training by 6/30/25. All managers were retrained and educated on 5/21/25 regarding the mandatory trainings that all staff should complete within their first year of hire. The program coordinator and executive director will be responsible for ensuring that all new staff are provided with the information and resources for mandatory trainings during orientation and continue to address training needs during individual supervision with each staff member. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of six clinical personnel records and two medical personnel records, the facility failed to demonstrate that a sufficient number of staff persons had CPR certification, as only two part time staff members were certified in CPR at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All full time staff will complete CPR and First Aid training by 6/30/2025. All new staff will be notified during the onboarding process that they should obtain CPR/First Aid training within 90 days of employment. Program director will be responsible for monthly training audits to ensure that sufficient staff are trained in CPR/ First Aid. |
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.
|
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 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The company 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) (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.
|
Observations
Based on a review of seven client records, the facility failed to ensure that informed and voluntary consent forms included the specific information to be disclosed in one record reviewed.
Client # 6 was admitted to the outpatient level of care on September 12, 2024 and was discharged on February 14, 2025. Four informed and voluntary consent forms to legal agencies that were signed and dated by the client on September 12, 2024, were missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Regulation 709.28 was reviewed with all staff during staff meeting on 5/15/25, and addressing the area of specific 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 to ensure that the specific information to be disclosed in completed it its entirety. Releases of information will be checked by every clinician prior to releasing information to any source. |
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.
|
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 seven of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
|
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 5/15/25 and will be implemented at each intake appointment beginning on 5/20/25. Program coordinator 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. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment and rehabilitation plans in four of seven client records reviewed.
Client # 1 was admitted to the outpatient activity on January 21, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 5, 2025; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 2 was admitted to the outpatient activity on January 9, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 16, 2025; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 3 was admitted to the outpatient activity on December 9, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 12, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 4 was admitted to the outpatient activity on July 29, 2024 and was discharged on February 27, 2025. The individual treatment and rehabilitation plan was completed on August 2, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
This is a repeat citation from the April 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff were retrained and educated on 5/27/25 regarding where to include the type and frequency of services within the client's treatment plan. The program coordinator will be responsible for ensuing that the type and frequency of services are included in the treatment plan through completing monthly chart audits. Any discrepancies identified by the program coordinator will be addressed with 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.
|
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 one of three applicable records reviewed.
Client # 5 was admitted on August 21, 2024 and was discharged on January 21, 2025. The treatment plan update completed on October 16, 2024, indicated that the client was to receive four individual counseling sessions per month; however, no individual counseling sessions were documented between December 2, 2024, and January 13, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff have been retrained and educated during staff meeting on 5/15/25 regarding the expectation of individual sessions and appropriate documentation of any missed treatment sessions. Program coordinator will complete weekly chart audits and address any late entries in individual supervision with each staff member. |