INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of two applicable personnel records reviewed.
Employee # 4 was hired as a counselor on December 15, 2025. The training in the use of fire extinguishers was not completed until July 14, 2026.
Employee # 5 was hired as a counselor on April 6, 2026. The training in the use of fire extinguishers was not completed until July 14, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28(c)(4) LICENSURE: Fire Safety
705.28 Fire Safety (c) Fire extinguishers. The nonresidential facility shall: (4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
- The Clinical Director or Designee will train staff on the use of fire extinguishers upon their employment. This training will be documented with a Certificate of Completion and placed in their employee file.
- Quality Assurance (QA) will monitor that staff are trained on the use of fire extinguishers upon their employment.
- Date: 10/31/2026
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two applicable personnel record reviewed.
Employee # 4 was hired as a counselor on December 15, 2025. The training in assigned tasks to complete during emergencies was not completed until July 14, 2026.
Employee # 5 was hired as a counselor on April 6, 2026. The training in assigned tasks to complete during emergencies was not completed until July 14, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.28(d)(3) LICENSURE: Fire Safety
705.28. Fire safety. (d) Fire drills. The nonresidential facility shall: (3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
- The Clinical Director or Designee will train staff on how to perform assigned fire safety tasks upon their employment. This training will be documented with a Certificate of Completion and placed in their employee file.
- QA will monitor that staff are trained on how to perform assigned fire safety tasks upon their employment.
- Date: 10/31/2026
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the September 2025 through July 2026 fire drill logs, the facility failed to ensure alternate exit routes were prepared to be used during fire drills.
At the time of the inspection, every monthly fire drill conducted during the reviewed period indicated the front door was used as the exit route and there was no other documentation indicating an alternate exit route was prepared to be used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28(d)(5) LICENSURE: Fire Safety
705.28 Fire safety. (d) Fire drills. The nonresidential facility shall: (5) Prepare alternate exit routes to be used during fire drills.
- The Facility Director and Director of Quality Assurance will retrain the Fire Marshall (Clinical Supervisor or Designee) on how to use and document alternate exit routes during fire drills.
- QA will monitor adherence to alternate exit routes during fire drills by reviewing the monthly fire drills.
- Date: 10/31/2026
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is to be made to on consent to release information forms in two of seven client records reviewed.
Client # 1 was admitted on January 7, 2026 and was still active at the time of the inspection. The release of information form to a primary care physician was signed by the client on January 7, 2026; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
Client # 4 was admitted on May 28, 2026 and was discharged on September 1, 2026. The release of information form to a primary care physician was signed by the client on May 28, 2026; however, the release form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The non-compliant Release of Information identified in this inspection (Client #1 - active) will be updated by 10/23/2026 to include the name of the person, agency, or organization to whom the disclosure will be made. The Clinical Supervisor and/or Designee will be responsible for monitoring adherence to this plan.
- The Facility Director and Director of Quality Assurance will retrain all staff on the appropriate way to complete a release of information, including writing the name of the person, agency or organization to whom disclosure is made. In the event that a client declines to complete a release of information, the staff will be trained to write "client declined" instead of leaving any portion of the form blank.
- QA will monitor adherence to the above process during routine unit chart reviews.
- Date: 10/31/2026
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