INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 15, 2026 through September 16, 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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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to maintain the confidentiality of client identity and records.
Client # 2 was admitted on May 14, 2026 and was still active at the time of the inspection. There was a letter to another treatment provider in the client record; however, the letter was for another client at the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
0271:
JFK's MATP has revised its First Dose Verification form with blank spaces that require staff to manually enter all required information including the name of the client. This revision eliminates the accidental inclusion of other client names on the document. The revision sharply minimizes potential violations of confidentiality of client identity and records.
The Clinical Supervisor is responsible for reviewing first dose confirmation forms to ensure JFK's compliance with this standard.
Date: September 24, 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 made on consent to release information forms in one of seven client records reviewed.
Client # 5 was admitted on January 21, 2026 and was discharged on August 21, 2026. There was a release of information form to an emergency contact, signed by the client on January 21, 2026, and a release of information form to another treatment provider, signed by the client on June 14, 2026, documented in the record; however, both release forms did not have documentation of the name of the person, agency or organization to whom the disclosures would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
0277:
On 9/28/2026, we completely revised our consent to release information form. The form more accurately reflects the type of information routinely released by the program. We also revised our consent form for use by hospitals or other providers. This form accurately reflects information routinely released to hospitals and other agencies.
In a staff training on 9/29/26, all staff were helped to understand that JFK is responsible for ensuring that consent forms are fully complete (name of client; organization to whom information is being released) prior to the release of any client information.
The Clinical Supervisor will ensure compliance with this standard.
Date: 09/29/2026
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire on consent to release information forms in two of seven client records reviewed.
Client # 5 was admitted on January 21, 2026 and was discharged on August 21, 2026. There was a release of information form to another treatment provider signed by the client on June 14, 2026, but the release form did not include documentation of the date, event or condition upon which the consent would expire.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
0287:
On 9/28/2026, we completely revised our consent to release information form. The form more accurately reflects the type of information routinely released by the program. We also revised our consent form for use by hospitals or other providers. This form accurately reflects information routinely released to hospitals and other agencies.
In a staff training on 9/29/26, staff were helped to understand that JFK is responsible for ensuring that consent forms are fully complete (including the date, event or condition upon which the consent will expire) prior to the release of any client information.
The Clinical Supervisor will ensure compliance with this standard.
Date: 09/29/2026
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered to the patient for maintenance treatment in one of three applicable patient records reviewed.
Patient # 1 was admitted on March 12, 2026 and was still active at the time of the inspection. The patient's first medication dose was received on March 12, 2026; however, the informed, written consent was signed by the client on March 18, 2026 and there was no documentation that the patient consented verbally prior to receiving their first dose.
This is a repeat citation from the September 24, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
M095:
JFK's program physician discusses and obtains an informed consent, voluntary consent from clients prior to the administration of methadone. Effective 9/22/26, should the physician's electronic signature pad fail and the client is unable to sign, the physician will complete a manual consent to treatment form with client and prior to the administration of methadone. This consent will be placed in the client's document library for reference.
The Clinical Supervisor is responsible for ensuring compliance with this standard.
Date: 09/22/2026
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 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 at least every sixty days in three of seven applicable client records reviewed.
Client # 1 was admitted on March 12, 2026 and was still active at the time of the inspection. A treatment plan update was completed on May 20, 2026 and the next update was due no later than July 20, 2026; however, the update was not completed at the time of the inspection.
Client # 2 was admitted on May 14, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 15, 2026 and the next update was due no later than July 15, 2026; however, the update was not completed until August 5, 2026.
Client # 6 was admitted on October 26, 2022 and was discharged on July 14, 2026. A treatment plan update was completed on November 12, 2025 and the next update was due no later than January 12, 2026; however, the update was not completed until January 21, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1883:
On 10/01/2026, staff received training regarding the timely completion of treatment plans. Although we have practiced a '50-day' JFK rule to update treatment plans since 2025, some staff continue to be late. Therefore, these staff will receive close monitoring effective 10/5/26. Utilizing the counselor case management log, close monitoring will proceed as follows:
*The supervisor and counselor will identify all treatment plans due for the current month;
*The supervisor will focus on those plans due during the first week of the month and select and date for their full completion.
*Prior to the end of the week, the supervisor will verify that all plans are timely completed.
*Counselors who do not complete their treatment plans as instructed will receive a supervisory warning and be referred to JFK's HR Director for appropriate corrective action.
Date: 10/5/2026
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