INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29, 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 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure all clinical supervisors and lead counselors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed. Employee # 5 was promoted to a lead counselor on June 30, 2025 and did not have documented clinical supervision experience prior to being promoted. There was no documentation indicating a Department-approved clinical supervision core curriculum training in the personnel record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: One of our councelors was promoted to the title of Lead Counselor for which our job description interpretation does not include a supervisory role, but more of a training role and liaison role between the counselors and leadership. For this reason, we did not require the Lead Counselor to obtain the core curriculum in clinical supervision provided by DDAP. Also, she did not have the 2 years of previous experience as a supervisor.
Action: We spoke with the Lead Counselor and had her schedule the core curriculum in clinical supervision training provided by DDAP. She is scheduled for the training from June 8 - 12, 2006.
Monitoring: Monitoring will be completed when the Lead Counselor produces evidence to the Clinical Director and Human Resources Manager that she successfully completed the core curriculum in clinical supervision course provided by DDAP. Her expected completion date is June 12, 2026.
All potential employees not currently employed with MTC or current employees desiring promotion to the position of Clinical Supervisor or Lead Counselor that have not functioned for 2 years as a supervisor in the provision of clinical services will be required to complete the core curriculum in clinical supervision training provided by DDAP prior to officially being hired to the position of Clinical Supervisor or Lead Counselor. |
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 review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.The facility policy and procedure stated that for all clients being discharged against medical advice the emergency contact will be called within twelve hours of when the client leaves treatment.Client # 12 was admitted to the inpatient non-hospital activity on December 5, 2025 and was discharged against medical advice on December 17, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's discharge at the time 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 counselor that worked with the patient attempting to leave treatment against medical advice did contact the emergency contact and helped the patient make arrangements with the emergency contact to pick up the patient. The counselor did not accurately document this per our facility policy and procedures for contacting and documenting that the emergency contact was notified within 12 hours of the client leaving treatment against medical advice.
Action: Staff were re-educated on § 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 and our policy requiring that clients discharging against medical advice have their emergency contact called within twelve hours of when the client leaves treatment.
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 contacting the emergency contact within 12 hours when a patient discharges against medical advice unless the patient has rescinded consent. 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 59 at times during the time frame of the previous inspection, conducted on May 14, 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. |