INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 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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709.92(a) 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:
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client, in accordance with the facility policy, in four of seven client records reviewed. The facility's policy and procedure manual stated a client initial treatment plan will be completed within 30 days of intake by a counselor or authorized staff. Client #1 was admitted on October 16, 2025 and discharged on March 30, 2026. The individual treatment plan was due to be completed no later than November 15, 2025; however, the plan was completed on November 18, 2025. Additionally, there was no written documentation indicating the treatment plan was developed with the client as both the client and counselor signed the plan on November 19, 2025.Client #3 was admitted on November 26, 2025 and discharged on March 16, 2026. The individual treatment plan was due to be completed no later than December 26, 2025; however, the plan was completed on January 21, 2026. Client #6 was admitted on December 15, 2025 and was active at the time of the inspection. The individual treatment plan was due to be completed no later than January 14, 2026; however, the plan was completed on January 21, 2026. Client #7 was admitted on December 5, 2025 and was active at the time of the inspection. The individual treatment plan was due to be completed no later than January 4, 2026; however, the plan was completed on January 22, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy regarding the timely completion of treatment plans was reviewed with staff during a staff meeting held on 5/1/26. Staff were re-educated on required treatment plan time frames and acknowledged understanding of the requirements. To ensure ongoing compliance, the Program Director will conduct monthly chart audits during staff supervision sessions to monitor timely completion of treatment plans and address any deficiencies identified. |
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 four of six applicable client records reviewed.Client #1 was admitted on October 16, 2025 and discharged on March 30, 2026. A treatment plan update was completed on January 15, 2026 and the next update was due no later than March 15, 2026; however, the update was not completed prior to dischargeClient #2 was admitted on October 20, 2025 and discharged on March 16, 2026. The individual treatment and rehabilitation plan was completed on November 21, 2025, and the first treatment plan update was due no later than January 20, 2026; however, the update was completed on January 27, 2026. Client #5 was admitted on August 27, 2025 and was active at the time of the inspection. A treatment plan update was completed on January 11, 2026 and the next update was due no later than March 12, 2026; however, the update was completed on March 25, 2026. Client #6 was admitted on December 15, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 21, 2026 and the first treatment plan update was due no later than March 22, 2025; however, the update was completed on March 25, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy regarding the timely completion of treatment plans was reviewed with staff during a staff meeting held on 5/1/26. Staff were re-educated on required treatment plan time frames and acknowledged understanding of the requirements. To ensure ongoing compliance, the Program Director will conduct monthly chart audits during staff supervision sessions to monitor timely completion of treatment plans and address any deficiencies identified. |