INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on May 26, 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 Treatment Centers 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)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure the individual training plan was based upon the employee's previous education, experience, current job functions and job performance in seven of twenty personnel records reviewed. Employee #5 was hired as a clinical supervisor on January 5, 2026. The individual training plan completed on January 5, 2026; however, the plan showed no indication that it was not based on the employee's previous education, experience, current job functions, and job performance. Employee #6 was hired as a clinical supervisor on April 13, 2026. The individual training plan completed on April 28, 2026; however, the plan showed no indication that it was not based on the employee's previous education, experience, current job functions, and job performance.Employee #8 was hired as a counselor on January 12, 2026. The individual training plan completed on February 12, 2026; however, the plan showed no indication that it was not based on the employee's previous education, experience, current job functions, and job performance.Employee #10 was hired as a counselor on October 6, 2025. The individual training plan completed on February 12, 2026; however, the plan showed no indication that it was not based on the employee's previous education, experience, current job functions, and job performance.Employee #11 was hired as a counselor on February 2, 2026. The individual training plan completed on February 12, 2026; however, the plan showed no indication that it was not based on the employee's previous education, experience, current job functions, and job performance.Employee #12 was hired as a counselor on February 24, 2026. The individual training plan completed on February 18, 2026; however, the plan showed no indication that it was not based on the employee's previous education, experience, current job functions, and job performance.Employee #13 was hired as a counselor on April 6, 2026. The individual training plan completed on March 25, 2026; however, the plan showed no indication that it was not based on the employee's previous education, experience, current job functions, and job performance.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Action Plan: Effective 6/12/2026, HR Coordinator provided education to site leadership on individualizing employee training plans. Effective 7/1/26, the facility will be implementing a revised training plan form specific to new hire employees.
Monitoring Method: HR Coordinator will utilize the onboarding audit tool for all new hires to ensure training plans are individualized and completed in their entirety. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility were unobstructed.At the time of the inspection, all emergency exit doors, except one on the second-floor clinical treatment services area, were locked from inside the facility and exiting was only accessible with a staff assigned key-fob. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Action Plan: Effective 7/15/26, the four-story rotunda stairwell doors identified during the survey that required staff fob access will be adjusted to ensure that exits are accessible to patients at all times. The magnetic locking system will be reconfigured to ensure accessibility. With this implementation, MTC will have two fully accessible exits from every floor of the program during any emergency. The Director of Plant Operations will be responsible for ensuring the reconfiguration successfully implements the accessibility of these exit doors.
Monitoring Method: During monthly environment of care inspections and emergency drills, all doors will be inspected for accessibility and obstructions. |
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 per facility policy, in two of six applicable client records reviewed.The facility policy and procedure manual stated that treatment and rehabilitation plans are to be updated at least every fourteen days.Client # 11 was admitted to the inpatient non-hospital activity on October 17, 2025 and was discharged on November 19, 2025. The individual treatment and rehabilitation plan was completed on October 15, 2025 and the first update was due no later than October 29, 2025; however, the update was not completed prior to discharge. Client # 14 was admitted to the inpatient non-hospital activity on January 11, 2026 and was discharged on March 17, 2026. A treatment plan update was completed on February 27, 2026 and the next update was due no later than March 13, 2026; however, the update was not completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action Plan: As of 6/9/26, Clinical Leadership has re-educated all counselors on facility policy regarding treatment planning to ensure treatment plan updates are completed every 14 days. Effective 6/30/26, a review of treatment plan updates coming due for the week will be added to the group supervision agenda. During weekly clinical group supervision, clinical leadership will review all treatment plans requiring updates.
Monitoring Method: Malvern Treatment Centers leadership conducts monthly chart audits to include the tracking of treatment plan updates every 14 days. The monthly PI will include a quality check of 20 charts to audit for treatment plan updates within timeframe. This monitoring plan will continue until 90% compliance has been reached for 3 months. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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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 documentation of a discharge summary, in three of four applicable client records reviewed.The facility policy and procedure manual stated that a discharge summary is to be completed within 7 days of discharge. Client # 11 was admitted to the inpatient non-hospital activity on October 17, 2025 and was discharged on November 19, 2025. The discharge summary was due to be completed no later than November 26, 2025; however, the summary was completed on December 2, 2025. Client # 12 was admitted to the inpatient non-hospital activity on October 18, 2025 and was discharged on November 5, 2025. There was no discharge summary documented in the record at the time of the inspection. Client # 13 was admitted to the inpatient non-hospital activity on December 2, 2025 and was discharged on January 5, 2026. There was no discharge summary 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
Action Plan: As of 6/9/26, Clinical Leadership re-educated the counselors on state regulation 709.53(a)(10) and facility policy to ensure discharge summaries are completed within 7 days of discharge. Effective 6/30/26, a review of discharge summaries coming due for the week will be added to the group supervision agenda. During weekly clinical group supervision, clinical leadership will review all client records requiring a discharge summary within timeframe.
Monitoring Method: Malvern Treatment Centers leadership conducts monthly chart audits to include the tracking of discharge summaries within 7 days of discharge. The monthly PI will include a quality check of 20 charts to audit for discharge summaries within timeframe. This monitoring plan will continue until 90% compliance has been reached for 3 months. |