INITIAL COMMENTS
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This report is a result of an off-site unusual incident investigation conducted on February 20, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the off-site unusual incidenet investigation, Malvern Treatment Centers was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the Patient Observation Rounds policy, along with an interview with the Director of Risk and Quality, the facility failed to follow written procedures for the management of treatment and rehabilitation services for clients.Per the Patient Observation Rounds policy, night shift staff must spend sufficient time to observe the rise and fall of the patient's chest no less than three times. According to the Director of Risk and Quality, an internal investigation was conducted, and three Behavioral Health Associates were witnessed, on video footage, not completing rounds as per protocol.
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Plan of Correction
Action Plan: The staff members identified as having completed rounds improperly are no longer employed with Malvern Treatment Centers. All CA staff members have already and/or will receive reeducation regarding the patient observation policy PC105 prior to their next working shift. This education includes the proper procedure for rounding, documentation, and monitoring of sleeping patients. To document training all staff members signed a rounding attestation which will be retained in their HR files.
Monitoring Method: Malvern Treatment Centers leadership team completes Leadership Observation Reviews as part of ongoing staff monitoring and training. The review tool has been updated to include additional camera observations of patient observation rounds. Reviews will be completed across shifts to include 20 camera reviews per month. The monthly PI will include an analysis of the Leadership Observation Rounds. This monitoring plan will continue until 100% compliance has been reached for 3 months. |
709.63(a)(4) LICENSURE Medication records
709.63. 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:
(4) Medication records.
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Observations
Based on the review of the client record, the facility failed to have a complete client record which includes medication records.Client # 1 was admitted on January 30, 2026, and discharged on February 4, 2026. The medication record indicates he is to take Lisinopril for high blood pressure and metformin for diabetes orally one time per day and Keppra for withdrawal seizures orally twice per day. These medications were not administered on 2/3/26. There is no reason written in the medication record as to why the medications were not administered as per doctor's orders.
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Plan of Correction
Action Plan: All nurses will receive reeducation regarding the nursing documentation policy PC139 this policy. This education includes the expectations for documentation related to refusals of medication, ancillary orders, and detox assessments. In order to execute this, the facility EMR has been updated to require a note be documented upon the input of a refused order.
Monitoring Method: Malvern Treatment Centers leadership conducts monthly chart audit to review identified quality indicators. These indicators will be updated to include a quality review of high-risk order refusals, daily detox assessment completion, and the corresponding documentation. The monthly PI will include a quality check of 20 charts to include the quality of documentation of refusals. This monitoring plan will continue until 90% compliance has been reached for 3 months. |