INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on September 21, 2026 through September 23, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital 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)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan was developed annually, with input from both the employee and the supervisor, in three of four applicable personnel records reviewed.Employee # 2 was hired as the facility director on April 13, 2026. There was no documentation of a current individual training plan, in the personnel record, at the time of the inspection.Employee # 3 was hired as the counselor on September 10, 2025. There was no documentation of a current individual training plan, in the personnel record, at the time of the inspection.Employee # 4 was hired as the counselor on December 23, 2025. There was no documentation of a current individual training plan, in the personnel 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
An approved Plan of Correction is not on file. |
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 Requirements Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframes in one of one applicable personnel records reviewed. Employee # 6 was hired as a behavioral health technician on February 16, 2024 and was due to have the HIV/AIDS training and the TB/STD training no later than February 16, 2026; however, both trainings were not completed as of the date of the inspection.This is a repeat citation from the October 9, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees, and visitors.At the time of the inspection, which was conducted on September 23, 2026 between 8:45 AM and 9:30 AM, the ceiling in the first-floor lobby entrance had evidence of water damage, which included what appeared to be mold, mildew, peeling paint, and cracks. Additionally, in the second-floor client lounge, there was a table which had several books placed under the legs to steady and balance the table out.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, the facility failed to ensure toilet paper was provided at each toilet at all times.At the time of the inspection, conducted on September 23, 2026 between 8:45 AM and 9:30 AM, the bathrooms located in client bedrooms #207 and #208 did not have toilet paper available.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, conducted on September 23, 2026 between 8:45 AM and 9:30 AM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times. At the time of the inspection, conducted on September 23, 2026 between 8:45 AM and 9:30 AM, in client bedroom #205 ' s bathroom, there was caulk covering a portion of shower stall floor in with evidence of what appeared to be mold/mildew, as well as dirt and grime.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers 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 all staff in the use of fire extinguishers upon staff employment in one of four applicable personnel records reviewed. Employee # 5 was hired as the director of nursing on June 1, 2026. There was no documentation, in the personnel record, indicating the fire extinguisher training was provided 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
An approved Plan of Correction is not on file. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of four applicable personnel records reviewed.Employee # 5 was hired as the director of nursing on June 1, 2026. There was no documentation, in the personnel record, indicating the employee was trained to perform assigned tasks during emergencies 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
An approved Plan of Correction is not on file. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's September 2025 through August 2026 fire drill logs, the facility failed to maintain a complete written fire drill record, which is to include the documentation of which exit route was used during the fire drill. At the time of the inspection, the fire drill log for the drill conducted in the month of February 2026 did not include documentation indicating which exit route was used during the fire drill. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's September 2025 through August 2026 fire drill logs, the facility failed to ensure a fire alarm or smoke detector was set off during each fire drill.At the time of the inspection, there was no indication the fire alarm or smoke detector was set off during the fire drill conducted in the month of February 2026 as the fire drill log did not include documentation that the fire alarm or smoke detector was set off during the drill.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to maintain an onsite photograph of each patient was submitted and approved by the Department for the September 13, 2024 and October 9, 2025 annual licensing inspections. Failing to maintain an onsite photograph of each patient was again found to be a deficiency in the September 21, 2026 through September 23, 2026 annual licensing inspection.A plan of correction for failing to complete treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the September 13, 2024 and October 9, 2025 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the September 21, 2026 through September 23, 2026 annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure each female patient was fully informed of the possible risks to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in two of two applicable patient records reviewed.Patient # 11 was admitted to the inpatient hospital activity on January 5, 2026 and was discharged on January 16, 2026. There was no documentation, in the record, indicating the female patient was fully informed of the possible risks to her or an unborn child at the time of the inspection. Patient # 14 was admitted to the inpatient hospital activity on March 23, 2026 and was discharged on April 17, 2026. There was no documentation, in the record, indicating the female patient was fully informed of the possible risks to her or an unborn child at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain onsite a photograph of each patient, which is to include the patient's name and date of birth, in three of nine applicable patient records reviewed. Patient # 3 was admitted to the inpatient hospital detoxification activity on January 5, 2026 and was discharged on January 10, 2026. There was no onsite photograph documented in the record at the time of the inspection.Patient # 9 was admitted to the inpatient hospital residential activity on June 30, 2026 and was still active at the time of the inspection. There was no onsite photograph documented in the record at the time of the inspection.Patient # 11 was admitted to the inpatient hospital activity on January 5, 2026 and was discharged on January 16, 2026. There was no onsite photograph documented in the record at the time of the inspection.This is a repeat citation from the September 13, 2024 and October 9, 2025 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician determined the proper dosage level for a patient and if the narcotic treatment physician determining the initial dose was not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient's initial dose and schedule in one of ten applicable patient records reviewed.Patient # 1 was admitted on to the inpatient hospital detoxification activity on August 20, 2026 and was discharged on August 26, 2026. There was documentation that a narcotic treatment physician conducted the patient examination on August 21, 2026; however, a different narcotic treatment physician determined the initial dose and schedule of buprenorphine on August 21, 2026. There was no documentation in the record indicating a consultation occurred between the two narcotic treatment physicians prior to the determination of the initial dose and schedule. This is a repeat citation from the October 9, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.Patient # 1 was transferred in and admitted to the inpatient hospital detoxification activity on August 20, 2026 and was discharged on August 26, 2026. There was no documentation indicating that the transferring narcotic treatment program was notified of the date of the patient's admission and date of the initial dose given to the patient as of the date of this inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
711.62(a)(6) LICENSURE Follow-up Information
711.62. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Follow-up information.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of five applicable client records reviewed.The facility's policy and procedure manual stated follow-up information will occur within seven days of discharge.Client # 16 was admitted to the inpatient non-hospital detoxification activity on July 21, 2026 and was discharged on July 24, 2026. There was no follow-up information documented in the record at the time of the inspection.Client # 18 was admitted to the inpatient non-hospital detoxification activity on April 6, 2026 and was discharged on April 11, 2026. There was no follow-up information 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
An approved Plan of Correction is not on file. |
711.63(e) LICENSURE Follow-up Policy
711.63. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on review of client records, the facility failed to follow the developed written client follow-up policy in two of two applicable client records reviewed. The facility's follow-up policy stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.Client # 16 was admitted to the non-hospital detoxification activity on July 21, 2026 and was discharged against medical advice on July 24, 2026. There was no documentation in the record indicating the emergency contact was notified of the client leaving the facility against medical advice.Client # 19 was admitted to the non-hospital detoxification activity on May 6, 2026 and was discharged against medical advice on May 9, 2026. There was no documentation in the record indicating the emergency contact was notified of the client leaving the facility against medical advice.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
711.64(b) LICENSURE Record Keeping System
711.64. Data Collection System.
(b) A drug and alcohol data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on an administrative review, the facility failed to maintain a drug and alcohol data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project' s performance. At the time of the inspection, facility staff were unable to provide any documentation or show any portion of the facility's electronic medical record which identified the accurate dates of when clients had level of care changes within the facility.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
711.52(a)(3) LICENSURE Mngt of Tx Services- Written Procedures
711.52. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services, which shall include, but not be limited to:
(3) Written procedures for the development, approval and ongoing 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 manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.Client # 25 was admitted on August 27, 2026 and was discharged against medical advice on September 1, 2026. There was no documentation in the record indicating the emergency contact was notified of the client leaving the facility against medical advice. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
711.52(c)(2) LICENSURE Type/Frequency of TX
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in three of four applicable patient records reviewed.Client # 22 was admitted to the inpatient non-hospital rehabilitation activity on January 16, 2026 and was discharged on February 11, 2026. The individual treatment and rehabilitation plan, completed on January 16, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive. Client # 24 was admitted to the inpatient non-hospital rehabilitation activity on February 23, 2026 and was discharged on March 10, 2026. The individual treatment and rehabilitation plan, completed on February 23, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.Client # 28 was admitted to the inpatient non-hospital rehabilitation activity on August 25, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on August 25, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
711.56(a) LICENSURE Written Termination Notice
711.56. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable client records reviewed.Client # 29 was admitted to the inpatient non-hospital rehabilitation activity on June 30, 2026 and was involuntarily terminated on July 4, 2026. There was no documentation, in the record, indicating the client received written notice of the project's involuntary termination decision.This is a repeat citation from the October 9, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
711.56(b) LICENSURE Right to Appeal Termination
711.56. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating his treatment.
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Observations
Based on a review of client records, the facility failed to ensure the client had an opportunity to request reconsideration of a facility decision to terminate treatment in one of one applicable client records reviewed.Client # 29 was admitted to the inpatient non-hospital rehabilitation activity on June 30, 2026 and was involuntarily terminated on July 4, 2026. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to keep patient records in accordance with applicable Federal drug and alcohol regulations in one of seven patient records reviewed.Patient # 4 was admitted to the inpatient hospital detoxification activity on February 9, 2026 and was discharged on February 15, 2026. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
710.42(b)(2) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(b) An individual treatment and rehabilitation plan shall be developed with each patient. This plan shall include, but not be limited to, written documentation of the following:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of patient records, the facility failed to document the type and frequency of treatment and rehabilitation services on the patient's individual treatment and rehabilitation plan in three of five applicable patient records reviewed.Patient # 9 was admitted to the inpatient hospital activity on June 30, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan, completed on July 1, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive. Patient # 10 was admitted to the inpatient hospital activity on January 5, 2026 and was discharged on January 16, 2026. The individual treatment and rehabilitation plan, completed on January 5, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive. Patient # 14 was admitted to the inpatient hospital activity on March 23, 2026 and was discharged on April 17, 2026. The individual treatment and rehabilitation plan, completed on March 24, 2026, did not include documentation of the type and frequency of treatment and rehabilitation services the patient was to receive. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |
710.42(c) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(c) Treatment and rehabilitation plans shall be reviewed and updated at least every 15 days.
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Observations
Based on a review of patient records, the facility to ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days in three of three applicable patient records reviewed.Patient # 8 was admitted to the inpatient hospital activity on August 26, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 26, 2026, and the first treatment plan update was due no later than September 10, 2026; however, the update was not completed at the time of the inspection. Patient # 9 was admitted to the inpatient hospital activity on June 30, 2026 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 1, 2026, and the first treatment plan update was due no later than July 16, 2026; however, the update was not completed at the time of the inspection.Patient # 14 was admitted to the inpatient hospital activity on March 23, 2026 and was discharged on April 17, 2026. The individual treatment and rehabilitation plan was completed on March 24, 2026, and the first treatment plan update was due no later than April 8, 2026; however, the update was not completed prior to discharge.This is a repeat citation from the September 13, 2024 and October 9, 2025 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An approved Plan of Correction is not on file. |