INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 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:
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Plan of Correction
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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.
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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.
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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.
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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.
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Observations
Based on a review of five personnel records, the facility failed to demonstrate that a sufficient number of staff persons had first aid training and CPR certification, as no full-time staff members were trained in first aid or CPR at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All full time staff will complete CPR and First Aid training by 5/23/2025. 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. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the June 2024 through March 2025 fire drill logs, the facility failed to document the exit route used during the November 2024 through March 2025 fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill logs were updated on 5/2/25 to include the exit route used during fire drills. All supervisory staff were educated and trained on the updated fire drill log on 5/2/25 and will begin implementing for the month of May 2025. The program director will review the fire drill log monthly for compliance and completeness. Results will be documented and discussed during monthly staff meetings. |
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.
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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.
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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 5/1/25 and will be implemented at each intake appointment beginning on 5/5/25. Program director 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 5/30/25. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed within seven days of service, in four of seven records reviewed.
Client # 2 was admitted on September 11, 2024 and was discharged on February 11, 2025. The record contained a progress note for an individual session that occurred on November 1, 2024, that was not completed until November 11, 2024. Additionally, the record contained progress notes for group sessions occurring on October 30, 2024 and November 1, 2024, that were not completed until November 8, 2024 and November 11, 2024, respectively.
Client # 3 was admitted on June 10, 2024 and was discharged on October 29, 2024. The record contained progress notes for group sessions occurring on August 13, 2024, August 15, 2024, August 20, 2024, August 22, 2024, August 27, 2024, August 29, 2024, and September 3, 2024, that were not completed until October 1, 2024.
Client # 4 was admitted on August 23, 2024 and was discharged on December 19, 2024. The record contained progress notes for group sessions occurring on August 27, 2024, August 29, 2024, September 3, 2024, September 5, 2024, and September 10, 2024, that were not completed until October 1, 2024.
Client # 6 was admitted on January 6, 2025 and was discharged on March 21, 2025. The record contained progress notes for individual sessions occurring on February 26, 2025 and March 6, 2025, that were not completed until April 1, 2025, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical and direct service staff were retrained on documentation standards, with a specific emphasis on the requirement to complete progress notes within seven calendar days of service delivery. The retraining occurred on 4/30/25 and included review of the relevant policy and documentation timelines. The program director will complete monthly chart audits and address any late entries in individual supervision with each staff member. |
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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in three of six applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed quarterly for the first year of treatment.
Client # 1 was admitted on August 5, 2024 and was discharged on February 24, 2025. The first case consultation note was completed on October 24, 2024. The second case consultation was due to be completed by January 23, 2025; however, no additional case consultation notes were completed prior to discharge.
Client # 2 was admitted on September 11, 2024 and was discharged on February 11, 2025. The first case consultation note was due to be documented by December 10, 2024; however, it was not documented until February 4, 2025.
Client # 7 was admitted on December 30, 2024 and was discharged on April 3, 2025. The case consultation note was due to be documented by March 30, 2025; however, the record did not contain a case consultation note.
This is a repeat citation from the May 13, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical and case management staff were retrained on the policy and procedures for case consultation documentation, with emphasis on the requirement for quarterly documentation during the first year of treatment. The retraining session occurred on 4/30/25, and included review of policy language, examples of appropriate case consultation content, and timelines for compliance. The program director will complete monthly chart audits to ensure compliance and address any concerns during individual supervision with staff members. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in two of three applicable records reviewed.
Client # 3 was admitted on June 10, 2024 and was discharged on October 29, 2024. The client record did not contain documentation of an aftercare plan.
Client # 6 was admitted on January 6, 2025 and was discharged on March 21, 2025. The client record did not contain documentation of an aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff were retrained on the policy and procedures for aftercare documentation. The retraining session occurred on 4/30/25, and included review of the policy relating to aftercare planning and review of appropriate completion of the aftercare planning. The program director will complete monthly chart audits to ensure compliance and address any concerns during individual supervision with staff members. |