INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2026 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(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.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of four applicable personnel records reviewed.Employee #4 was hired as a counselor on December 23, 2024. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than December 23, 2025. There was documentation showing that the HIV/AIDS training was completed; however, there was no documentation indicating the TB/STD training was completed as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will develop training on HIV/AIDS and TB/STD that comply with DDAP training requirements by 5/30/26. All new employees will complete these training courses within their first 30 days of employment. All current staff members who have not received these trainings will complete the training by 6/30/26. The Program Director will ensure training compliance through monthly training reviews during staff supervision. |
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 consent to release information forms in two of fourteen client records reviewed. Client #5 was admitted to the partial hospitalization activity on July 7, 2025 and was discharged on July 18, 2025. A release of information form for an outside health center was signed and dated by the client on July 3, 2025; however, there was no specific information to be disclosed documented on the release form. Client #9 was admitted to the outpatient activity on September 9, 2025 and was active at the time of the inspection. A release of information form for an outside health center was signed and dated by the client on September 4, 2025; however, there was no specific information to be disclosed documented on the release form. This is a repeat citation from the April 24, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff received re-education on 5/6/2026 the Release of Information (ROI) process, including proper manual completion procedures, specifically emphasizing specific information to be disclosed. Moving forward, daily chart audits will be conducted by the program director to ensure all Releases of Information are completed accurately. |
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 include the purpose of the disclosure on consent to release information forms in three of fourteen client records reviewed.Client #5 was admitted to the partial hospitalization activity on July 7, 2025 and was discharged on July 18, 2025. A release of information form to an outside health center was signed and dated by the client on July 3, 2025; however, there was no purpose of the disclosure documented on the release form.Client #9 was admitted to the outpatient activity on September 9, 2025 and was active at the time of the inspection. There were release of information forms to an outside health center and a friend that were signed and dated by the client on September 4, 2025; however, there was no purpose of the disclosure documented on either release form.Client #11 was admitted to the outpatient activity on July 21, 2025 and was discharged on November 3, 2025. A release of information form to a transportation agency was signed and dated by the client on June 17, 2025; however, there was no purpose of the disclosure documented on the release form.This is a repeat citation from the April 24, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff received re-education on 5/6/2026 the Release of Information (ROI) process, including proper manual completion procedures, specifically emphasizing purpose of disclosure. Moving forward, daily chart audits will be conducted by the program director to ensure all Releases of Information are completed accurately. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in five of fourteen client records reviewed.Client #1 was admitted to the partial hospitalization activity on August 29, 2025 and was discharged on September 16, 2025. A release of information form to a funding source was signed and dated by the client on August 28, 2025; however, there was no documentation in the record indicating a copy of the consent was offered to the client.Client #6 was admitted to the partial hospitalization activity on April 20, 2026 and was active at the time of the inspection. A release of information form to a government agency was signed and dated by the client on April 21, 2026; however, there was no documentation in the record indicating a copy of the consent was offered to the client.Client #9 was admitted to the outpatient activity on September 9, 2025 and was active at the time of the inspection. Release of information forms to a funding source and a friend were signed and dated by the client on September 4, 2025; however, there was no documentation in the record indicating a copy of either consent was offered to the client.Client #11 was admitted to the outpatient activity on July 21, 2025 and was discharged on November 3, 2025. A release of information form to a transportation agency was signed and dated by the client on June 17, 2025; however, there was no documentation in the record indicating a copy of the consent was offered to the client.Client #12 was admitted to the outpatient activity on October 31, 2025 and was discharged on February 17, 2026. A release of information form to a funding source was signed and dated by the client on October 31, 2025; however, there was no documentation in the record indicating a copy of the consent was offered to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff received re-education on 5/6/2026 the Release of Information (ROI) process, including proper manual completion procedures, specifically emphasizing offering the client a copy of their consent form. Moving forward, daily chart audits will be conducted by the program director to ensure all Releases of Information are completed accurately. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records and discussions with project staff, the project failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.The facility's policy and procedure manual stated that all client records shall be maintained in a secure Electronic Medical Record (EMR) system. This policy applies to all client records created and maintained by the behavioral health providers and administrative staff, including clinical notes, assessments, treatment plans, progress notes, billing documentation and correspondence. At the time of the inspection, the facility reported they do not maintain paper client records and all paper documentation is to be scanned into the electronic record by the staff in a timely fashion. During the client record review, many of the client documents, including intake documents, the initial and comprehensive treatment plans, and treatment plan updates, which were documented to have been completed in 2025, were uploaded or linked to the client medical record within a few days of this inspection's start date. Per project staff, the documentation was not uploaded to the electronic record timely.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/6/2026, all staff have been retrained on the timely uploading of all paper documents into each client's electronic medical record. Training emphasized the importance of prompt documentation and reviewed required timeframes for uploading all records, with specific focus on treatment plans. Staff were re-educated that completed treatment plans must be uploaded to the client's EMR within 24 hours of completion.
To ensure ongoing compliance, the supervisor will conduct monthly chart audits to verify that the complete client record, including all paper documentation, is accurately uploaded and accessible within the client's electronic medical record. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to develop a recordkeeping system that allowed for the identification of client's admissions and discharges within a specific time period. At the time of the inspection, the requested list of active and discharged clients, provided by facility staff, included dates for when the clients were receiving services at different Department-licensed facilities within the project. This is a repeat citation from the April 24, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed and revised its recordkeeping procedures to ensure that admissions and discharges are accurately tracked and identifiable by the specific licensed facility providing services. Separate tracking measures have been implemented to distinguish client participation at each Department-licensed location within the project.
The Program Director will implement an updated census tracking spreadsheet and discharge log were created to clearly identify; Client admission date to the specific facility, Client discharge date from the specific facility, Current client status (active/discharged) and Level of care and program assignment. |
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 six applicable client records reviewed.Client #10 was admitted to the outpatient activity on October 29, 2025 and was active at the time of the inspection. A treatment plan update was completed on January 8, 2026, and the next update was due no later than March 9, 2026; however, the update was completed on March 20, 2026.Client #13 was admitted to the outpatient activity on July 16, 2025 and was discharged on February 2, 2026. A treatment plan update was completed on November 3, 2025, and the next update was due no later than January 3, 2026; however, the update was completed on January 8, 2026.Client #14 was admitted to the outpatient activity on December 5, 2025 and was discharged on March 18, 2026. The individual treatment and rehabilitation plan was completed on January 9, 2026, and the first update was due no later than March 10, 2026; however, the update was not completed prior to discharge. This is a repeat citation from the May 16, 2022, May 23, 2023, May 7, 2024, and April 24, 2025 annual licensing renewal inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility conducted an immediate audit of all active client charts to identify treatment and rehabilitation plans that were overdue for review and update. Any plans identified as noncompliant were updated immediately with the client and clinical staff participation.
The facility also reviewed prior corrective actions and determined that existing monitoring processes were insufficient to ensure ongoing compliance. As a result, a revised tracking and accountability process has been implemented.
To ensure sustained compliance with treatment plan update requirements, the facility has implemented the following corrective measures:
A centralized treatment plan tracking system was developed to monitor due dates for all treatment and rehabilitation plan reviews. Electronic and calendar-based reminders will be utilized to notify primary therapists and supervisors 30 days prior to treatment plan expiration dates. Clinical supervisors will conduct weekly chart audits to monitor compliance with 60-day treatment plan updates. A monthly compliance report will be reviewed during leadership and clinical supervision meetings to address any outstanding deficiencies immediately. Therapists and clinical staff received retraining regarding regulatory requirements for treatment plan review timelines and documentation expectations. The program director will be responsible to ensure that all corrective actions are implemented and followed. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to ensure treatment and rehabilitation plans are updated at least every sixty days was submitted and approved by the Department for the April 24, 2025, May 7, 2024, May 23, 2023, and May 16, 2022 annual licensing inspections. Failing to ensure treatment and rehabilitation plans are updated at least every sixty days was again found to be a deficiency in the April 29, 2026, annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
he facility conducted an immediate audit of all active client charts to identify treatment and rehabilitation plans that were overdue for review and update. Any plans identified as noncompliant were updated immediately with the client and clinical staff participation.
The facility also reviewed prior corrective actions and determined that existing monitoring processes were insufficient to ensure ongoing compliance. As a result, a revised tracking and accountability process has been implemented.
To ensure sustained compliance with treatment plan update requirements, the facility has implemented the following corrective measures:
A centralized treatment plan tracking system was developed to monitor due dates for all treatment and rehabilitation plan reviews. Electronic and calendar-based reminders will be utilized to notify primary therapists and supervisors 30 days prior to treatment plan expiration dates. Clinical supervisors will conduct weekly chart audits to monitor compliance with 60-day treatment plan updates. A monthly compliance report will be reviewed during leadership and clinical supervision meetings to address any outstanding deficiencies immediately. Therapists and clinical staff received retraining regarding regulatory requirements for treatment plan review timelines and documentation expectations. |