INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Malvern Institute for Psychiatric and Alcoholic Studies, Inc. 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 received 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 five applicable personnel records reviewed.Employee #21 was hired as a clinical aide on December 11, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than December 11, 2025. There was no documentation of the completion of both trainings 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
Identification of Failure: The employee was hired as a per diem employee and was provided the dates for training but did not attend the training as expected. The employee should have been removed from employment for not completing the expected training but was not removed.
Action: The employee was removed from the current employee list and may be eligible for rehire once the HIV/AIDS and TB/STD training is completed. The Human Resources Director/Designee and the Clinical Director will assure all staff are notified of required trainings and provided opportunities to receive required trainings prior to expected completion dates for the required trainings
Monitoring: Monitoring will be completed monthly by the Human Resources Director/Designee and Clinical Director to assure all staff are notified of required trainings and provided opportunities to receive required trainings prior to expected completion dates for the required trainings. Employees that do not receive the required trainings by the expected completion date will be removed from the schedule until they complete the required training and may have their current employment status evaluated if they do not become compliant in a reasonable amount of time. Monthly reports will be made to the MTC Director of PI/RM to assure compliance with monitoring. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the May 2025 through April 2026 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.The facility is residential and provides services twenty-four hours a day, seven days a week; however, there were no fire drills conducted on Saturday or Sunday staffing shifts during the entire period reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Although the fire drills were completed on different days and on different staffing shifts for every month, there was not at least one weekend fire drill completed since the last DDAP survey.
Action: The Director of Maintenance will assure that at least one weekend fire drill will be completed yearly on either a Saturday or Sunday and recorded per facility expectations.
Monitoring: Monitoring will be completed monthly by the Director of Maintenance and reported to the MTC Director of PI/RM to assure compliance with regulation 705.10 Fire Safety (d) Fire drills (7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. Compliance will be reported monthly during the monthly Safety Committee meetings. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.Client # 13 was admitted to the inpatient non-hospital activity on November 11, 2025 and was discharged against medical advice on December 9, 2025. The release of information form to the emergency contact was rescinded by the client on December 9, 2025 at 5:00 p.m.; however, the aftercare plan documented that the emergency contact was notified of the client's discharge after the release form was rescinded.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The patient relayed to his counselor that he wanted to leave treatment early. To convince the patient to stay in treatment, the counselor called the emergency contact to help convince the patient to remain in treatment. It was at this point that the patient decided to rescind his consent for the release of information. The counselor documented the encounter later, after the incident, and did not specify in the documentation that they called the emergency contact prior to the patient rescinding the consent.
Action: Staff were re-educated on § 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 and the need to accurately document the sequence of events as they occurred.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with § 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. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 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 according to facility policy in two of six applicable client records reviewed. The facility policy and procedure manual stated that treatment and rehabilitation plans will be updated every fourteen days for those clients in the inpatient non-hospital level of care.Client # 9 was admitted to the inpatient non-hospital activity on April 21, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 25, 2026 and the first update was due no later than May 9, 2026; however, the update was not completed until May 13, 2026. Client # 13 was admitted to the inpatient non-hospital activity on November 11, 2025 and was discharged on December 9, 2025. The individual treatment and rehabilitation plan was completed on November 10, 2025 and the first update was due no later than November 24, 2025; however, the update was not completed until December 5, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The two missed due dates for the treatment plan updates were an oversight by the same counselor that had been experiencing some personal health issues causing missed days from work. There was a breakdown in communication at these times that lead to the missed updates.
Action: Counselors were re-educated on 709.52. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days. Counselors were re-educated that treatment plan updates need to be completed within 14-days per our policy and that upcoming treatment plan updates will be discussed during the treatment team meetings to assure counselors and supervisors are aware of upcoming due dates and arrangements are made to assure compliance with the expectations.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with 709.52. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days. Audits will assure compliance with the MTC policy of completing treatment plan updates every 14 days. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an administrative review, the facility failed to notify the Department within 90 days of the change in authorized maximum capacity.The facility reported and confirmed the census for the inpatient non-hospital activity was over the maximum licensed capacity of 76 at times during the time frame of the previous inspection, conducted on May 7, 2025, through the date of this inspection. There were no capacity increase requests approved during the reviewed period and there was no documentation the Department was notified within 90 days of the capacity change. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The facility had a greater number of rehabilitation level of care patients due to patients stepping down from a detoxification level of care than are indicated as the capacity level for the rehabilitation level of care on our license. A request for an exemption was not made within 90 days of the occurrence. As an organization, we have experienced a greater variability in acuity that will require greater flexibility in capacity for specific level of care beds.
Action: The Director of PI/RM will apply for an exemption and request a permanent increase in the rehabilitation level of care bed capacity to accommodate a growing number of rehabilitation level of care patients. Once an appropriate capacity level is determined, leadership will request an increase in bed capacity for the rehabilitation level of care.
Monitoring: Monitoring will be completed daily during the facility "Flash" meeting to assure compliance with capacity levels and make arrangements to notify DDAP and make capacity increase requests as appropriate when the facility nears its designated capacity limits. Any concerns or trends related to level of care bed capacity will be reported to the Director of PI/RM and discussed during the monthly PI meetings to determine if flex bed exemptions are warranted and should be submitted to DDAP. |