INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2024 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure written individual training plans had input from both the employee and the supervisor in one of three applicable personnel records reviewed.
Employee # 2 was hired as a counselor on July 24, 2023. The individual training plan was signed by the employee on July 24, 2023, but there was no documentation that the plan was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Site director met with staff on 5/3/2024 to review the process of completing individual training plans. It was specifically reviewed that all training plans need to include input from the staff and supervisor and have signature's from both on every training plan. HR administrator will conduct ongoing HR file reviews at time of hire and annually to ensure ongoing compliance. New training form was created on 5/3/24 to include documented input from both the employer and the employee to list the goals and training objectives for the upcoming year. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The facility had multiple fire extinguishers in place; however, there was no verification that they were inspected and approved annually by either the local fire department or fire extinguisher company.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
on 5/2/2024 Site Director and CEO have communicated with MVP Recovery's fire extinguisher company the need for annual fire extinguisher inspections. Fire extinguisher company came out to inspect the fire extinguishers on 5/17/2024. This will now be conducted ongoing and will be submitted by the fire extinguisher company to MVP Recovery in writing for continued compliance. Moving forward all fire extinguishers will be inspected by the fire extinguisher company every January so it will be maintained annually. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project had an exception to the regulation requiring an audit if the project's gross income is less than $500,000. However, the project provided a copy of their 2022 tax return indicating that the gross income exceeded $500,000 for the project's previous fiscal year; therefore, the exception is no longer valid and an financial audit must be completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
MVP Recovery has obtained the services of a public independent certified public account for ongoing accounting services. MVP Recovery has obtained the services of a Independent Accounting Firm and CEO has signed off on a contract with this accounting company to conduct our annual financial audits. This will be a maintained contract ongoing for services overseen by the CEO. The audit is expected to be completed by 7/1/2024. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in two of two applicable client records reviewed.
Client # 4 was admitted to the outpatient activity on August 8, 2023 and was administratively discharged on November 9, 2023. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
Client # 8 was admitted to the outpatient activity on September 22, 2023 and was administratively discharged on October 6, 2023. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Site director conducted a staff education on the policy and procedure of involuntary termination of client services during a staff meeting on 5/3/2024. It was specifically reviewed that when an involuntary discharge is being conducted, that the client is to be notified of discharge in writing which includes the reason for discharge. Site director will conduct reviews of all discharges to ensure that notification in writing is given for any involuntary discharges of clients from services to monitor ongoing compliance. |
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, the facility failed to ensure individual treatment and rehabilitation plans were developed with the client in three of seven applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on November 2, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than December 2, 2023; however, the individual treatment and rehabilitation plan was completed on January 11, 2024. Additionally, there was no documentation that the treatment plan was developed with the client.
Client # 2 was admitted to the outpatient activity on January 3, 2024 and was still active at the time of the inspection The individual treatment and rehabilitation plan was due to be completed no later than February 3, 2024; however, the individual treatment and rehabilitation plan was completed on February 15, 2024.
Client # 4 was admitted to the outpatient activity on August 8, 2023 and was discharged on November 9, 2023. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director conducted a staff meeting on 5/9/2024 to review the policy of treatment plans and updated treatment plans for all staff. Chart audits will be conducted both in supervision with staff and independently by director to ensure ongoing compliance of treatment plan timeframes remain in compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment and rehabilitation plans in five of six applicable client records reviewed.
Client # 1 was admitted to the outpatient activity on November 2, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 11, 2024; however, there was no type and frequency of treatment services listed on the plan.
Client # 3 was admitted to the outpatient activity on February 2, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 20, 2024; however, there was no type and frequency of treatment services listed on the plan.
Client # 5 was admitted to the outpatient activity on December 27, 2023 and was discharged on March 29, 2024. The individual treatment and rehabilitation plan was completed on January 4, 2024; however, there was no type and frequency of treatment services listed on the plan.
Client # 6 was admitted to the outpatient activity on November 6, 2023 and was discharged on March 5, 2024. The individual treatment and rehabilitation plan was completed on November 30, 2023; however, there was no type and frequency of treatment services listed on the plan.
Client # 7 was admitted to the outpatient activity on January 10, 2024 and was discharged on April 3, 2024. The individual treatment and rehabilitation plan was completed on January 29, 2024; however, there was no type and frequency of treatment services listed on the plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director conducted a staff meeting on 5/9/2024 to review the policy of treatment plans and the requirements of what is to be included on all treatment plans. Director specifically reviewed the necessary information of type and frequencies of treatment services to be included on each treatment plan. Direction will conduct chart audits both in supervision with staff and independently to ensure ongoing compliance with required information on all treatment plans. |
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 maintain a complete client record, which is to include the documentation of follow-up information, in three of four applicable client records reviewed.
Client # 5 was admitted to the outpatient activity on December 27, 2023 and was discharged on March 29, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 6 was admitted to the outpatient activity on November 6, 2023 and was discharged on March 5, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 7 was admitted to the outpatient activity on January 10, 2024 and was discharged on April 3, 2024. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site director conducted a staff meeting on 5/9/2024 and provided staff education on the policy and procedure of documented follow ups after discharge. Director will conduct audits of discharges ongoing to ensure that ongoing follow up outreach is conducted and documented in compliance with the policy and procedure. |