INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility January 2025 through December 2025 training year in one of two applicable personnel records reviewed. Employee #5 was hired as a counselor on September 26, 2024. The personnel record documented 14 hours of annual training during the period reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the personnel and training record for Employee #5 immediately upon identification of the deficiency. Employee #5 has been scheduled to complete the remaining required training hours in the areas identified under regulation. Documentation of completed trainings will be maintained in the employee personnel file.
The facility conducted an audit of all counselor personnel and training records to ensure compliance with the annual 25-hour training requirement. Any staff identified as deficient in required annual training hours will be assigned additional training and monitored until compliance is achieved.
The facility has implemented a revised Staff Development Tracking System to monitor annual training completion for all counselors and lead counselors. The tracking log will include:
Required annual training hours completed
Training topics completed
Dates of completion
Remaining hours needed for compliance
The Clinical Supervisor will review training records on a quarterly basis to ensure counselors remain on track to complete all required annual training hours before the end of each training year.
Going forward, all newly hired counselors will receive orientation regarding annual training requirements at the time of hire, including required timelines and documentation procedures. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's April 2025 through March 2026 fire drill logs, the facility failed to prepare alternate exit routes to be used during the fire drills. At the time of the inspection, every fire drill completed during the reviewed period utilized the front door as the exit route. There was no other documentation indicating alternate exits were used during the fire drills.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has identified and designated alternate evacuation routes and exits throughout the building to be utilized during future fire drills and emergency evacuations. Updated fire drill procedures have been developed to require rotation of evacuation routes during monthly fire drills. Staff have been educated on the importance of utilizing varying exits and documenting the specific exit route used during each drill. Fire drill documentation forms have been revised to include a section identifying the exit route utilized and confirming whether the primary or alternate route was used.
The Program Director will monitor monthly fire drill documentation to ensure alternate exits are rotated appropriately. A schedule will be maintained to ensure all available exits are practiced regularly throughout the year. Fire safety procedures and evacuation routes will be reviewed. |
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 two of seven client records reviewed.Client #1 was admitted on July 11, 2025 and was discharged on November 3, 2025. There was a release of information form to a technology service that was signed and dated by the client on July 10, 2025; however, the form did not include whether a copy of the consent form was offered to the client.Client #3 was admitted on October 16, 2025 and was discharged on January 23, 2026. There was a release of information form to a probation and parole office that was signed and dated by the client on October 9, 2025; however, the form did not include whether a copy of the consent form was offered to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/20/2026 all clinical staff were retrained on proper documentation procedures for informed consent and release of information, including, Requirement to offer a copy of the signed consent to every client, proper completion of the updated ROI form and overall documentation standards for compliance
The Clinical Supervisor will conduct chart audits at the time of creation as well as continued monthly audits to ensure, ROI forms are fully completed, documentation confirms that a copy was offered to the client and copies are properly filed in the client record. Clinical supervisor will conduct bi-weekly audits of charts, pulling 3 charts per staff member to ensure continue compliance.
Findings from audits will be reviewed during supervision meetings. Any deficiencies will result in immediate corrective action, including re-training and correction.
The facility will incorporate ROI documentation compliance into its quarterly performance improvement review to ensure sustained adherence to regulatory requirements. |
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. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to include, as part of the intake and admission process, documentation of a consent to treatment in three of seven client records reviewed.Client #4 was admitted on September 22, 2025 and was discharged on February 19, 2026. There was no documentation of a signed consent to treatment in the record prior to discharge.Client #6 was admitted on October 20, 2025 and was active at the time of the inspection. There was no documentation of a signed consent to treatment in the record prior to discharge.Client #7 was admitted on January 29, 2026 and was active at the time of the inspection. There was no documentation of a signed consent to treatment in the record prior to discharge.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility conducted an immediate review of all active client records to identify any missing consent to treatment forms. Intake staff and clinical staff were re-educated on required admission documentation 5/20/2026, including the requirement that consent to treatment forms be signed and filed prior to or upon admission.
The facility has implemented an updated intake checklist requiring staff verification of all admission documents, including consent to treatment, before a chart may be considered complete. Clinical Director will conduct weekly chart audits for all new admissions to ensure required documentation is present and properly completed. Any missing documentation identified during audits will be corrected immediately and reviewed with the responsible staff member. Compliance with intake documentation requirements will be reviewed during staff meetings and new employee orientation. |