INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 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(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, as only one of the three full-time staff members was trained in first aid between February 1, 2025 and March 24, 2025.
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 5/2/2025. 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. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on April 3, 2025, the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer in each bathroom. The first-floor client restroom did not have any soap, paper towels, or an operable mechanical dryer.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 4, 2025, the Regional Director issued a formal notice to all facility staff, directing them to complete daily facility rounds. This directive specifically emphasized the requirement to check all restrooms and ensure that bathroom supplies (toilet paper, soap, paper towels, etc.) are fully stocked.
The Program Director will conduct weekly audits of the daily rounds checklist to verify that staff are consistently completing their assigned duties.
Any discrepancies or incomplete checklists will be addressed immediately through staff coaching or corrective measures as appropriate.
The Handruer in first floor bathroom was repaired 4/6/25. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from September 2024 through March 2025, the facility failed to conduct unannounced fire drills during the 2024 months of September, October, November and December.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's Operations Specialist will be responsible for scheduling and executing unannounced fire drills on a rotating shift and time basis. A fire drill log review checklist was developed on 4/22/25 to verify that each drill is unannounced and documented accordingly. All supervisory staff received retraining on fire drill procedures on 4/22/25, with emphasis on the importance of unannounced drills and accurate documentation. 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 eight of eight applicable records reviewed.
Client # 1 was admitted on February 1, 2025 and was discharged on February 17, 2025.
Client # 2 was admitted on February 1, 2025 and was discharged on February 27, 2025.
Client # 3 was admitted on February 1, 2025 and was discharged on March 10, 2025.
Client # 4 was admitted on February 1, 2025 and was discharged on March 3, 2025.
Client # 5 was admitted on February 4, 2025 and was active at the time of the inspection.
Client # 6 was admitted on February 5, 2025 and was active at the time of the inspection.
Client # 7 was admitted on February 5, 2025 and was active at the time of the inspection.
Client # 8 was admitted on February 10, 2025 and was active at the time of the inspection.
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. |
709.92(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.
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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 two of six applicable records reviewed.
Client # 7 was admitted on February 5, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on February 5, 2025, indicated that the client was to receive two individual counseling sessions per month; however, only one individual session was documented for the month of March 2025.
Client # 8 was admitted on February 10, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on February 19, 2025; however, the record did not contain documentation of any counseling sessions during March 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director re-educated staff on 4/22/25 regarding the requirement that treatment services included on the individual treatment plan must match the client's obtained services and that all missed services by the client need to be documented in the chart. Beginning the week of 4/28/25, the Program director will perform chart audits in weekly supervision with staff to ensure that the services obtained are following the services detailed in the treatment plan. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within seven days of discharge, per facility policy, in four of four applicable records reviewed.
Client # 1 was admitted on February 1, 2025 and was discharged on February 17, 2025. The client record did not contain documentation of follow-up information.
Client # 2 was admitted on February 1, 2025 and was discharged on February 27, 2025. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on February 1, 2025 and was discharged on March 10, 2025. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on February 1, 2025 and was discharged on March 3, 2025. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director created a tracking system for all client discharges to include the date that the discharge follow up needs to be completed by. Once a client is discharged, their primary counselor will add them to the discharge list and document when the follow up is completed. The program director will completed monthly checks of the discharge follows up documents to ensure compliance. All staff were educated and trained on this process on 4/30/25. The implementation of this process will begin on 5/5/25. |