INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2025 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's June 2024 through July 2025 training year in one of one applicable personnel record reviewed.
Employee #5 was hired as a counselor on February 5, 2024. The personnel record documented 20.5 hours of annual training during the training year reviewed.
This is a repeat citation from the September 25, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. 0083: 704.11(f)(2) Licensure Trng Hours Req-Coun:
All counselors will complete at least 25 clock hours of training annually in areas such as (i) Client recordkeeping, (ii) Confidentiality, (iii) Pharmacology, (iv) Treatment planning, (v) Counseling techniques, (vi) Drug and Alcohol Assessment, (vii) Codependency, (viii) Adult Children of Alcoholics (ACOA) issues, (ix) Disease of addiction, (x) Aftercare planning, (xi) Principles of Narcotics Anonymous, (xii) Ethics, (xiii) Substance abuse trends, (xiv) Interaction of addiction and mental illness, (xv) Cultural awareness, (xvi) Sexual harassment, (xvii) developmental psychology, and (xvii) Relapse prevention. The Clinical Supervisor will create a training plan with each counselor on an annual basis to complete the 25 required clock hours of training in the above domains. The Clinical Supervisor will then review the counselors training hours in weekly supervision to ensure that the counselor obtains the 25 required clock hours of training annually. The Clinical Supervisor will submit each training certificate to Quality Assurance for monitoring of this practice.
Completion Date: 11/1/2025
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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in six of six applicable client records reviewed.
Client #1 was admitted on March 21, 2022 and was discharged on August 18, 2025. There was a release of information form to the funding source signed and dated by the client on September 24, 2024; however, the form was valid for one day and expired on September 24, 2024. There was documentation of disclosures to the funding source from September 25, 2024 through the date of discharge.
Client #3 was admitted on January 7, 2025 and was discharged on May 29, 2025. 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.
Client #4 was admitted on December 19, 2024 and was discharged on April 14, 2025. 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.
Client #5 was admitted on January 7, 2025 and was active at the time of the inspection. There was a release of information form to the funding source signed and dated by the client on September 8, 2025; however, there was documentation of disclosures, without a valid release form, to the funding source from January 7, 2025 through September 7, 2025.
Client #6 was admitted on March 4, 2025 and was active at the time of the inspection. There was a release of information form to the funding source that was signed and dated by the client on May 13, 2025; however, there was documentation of disclosures, without a valid release form, to the funding source from March 4, 2025 through May 12, 2025.
Client #7 was admitted on December 17, 2024 and was active at the time of the inspection. There was a release of information form to the funding source that was signed and dated by the client on September 9, 2025; however, there was documentation of disclosures, without a valid release form, to the funding source from December 17, 2024 through September 8, 2025.
This is a repeat citation from the September 25, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
2. 0276 : 709.28 (c) Licensure Confidentiality:
Every active client in treatment will meet in-person with their counselor to complete annual releases of information. Every consent form, including but not limited to: funding source; transportation agency; primary care physician; and emergency contact will contain the dated signature of the client and the witness. In the Electronic Medical Record, a notification will be entered into each client's chart to provide the therapist and supervisor with a visual reminder of the due date for the annual releases. The Clinical Supervisor will review client records on a regular basis during individual supervision to ensure that all informed and voluntary release of information forms are signed and dated by the client. The Clinical Supervisor will monitor the completion of the annual consent packet two months prior to expiration date recorded in the Electronic Medical Record in order to ensure full compliance with the regulatory requirements. We are implementing an electronic monitoring/tracking system that involves staff, Clinical Supervisor, and Quality Assurance Officer which will alert to all involved the required completion dates of the documentation. The Facility Director is responsible for this action. Quality Assurance Officer will monitor the completion and compliance of this practice during chart reviews.
Completion Date: 11/1/2025
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgment by clients that they had been notified of their client rights in three of five applicable client records reviewed.
Client #5 was admitted on January 7, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client was not notified of their rights until September 8, 2025.
Client #6 was admitted on March 4, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client was not notified of their rights until May 13, 2025.
Client #7 was admitted on December 17, 2024 and was active at the time of the inspection. There was documentation in the record indicating the client was not notified of their rights until September 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
3. 0296 : 709.30 Licensure Client Rights:
Every active client in treatment will meet in-person with their counselor to document written acknowledgement of client rights upon admission and annually thereafter. The Clinical Supervisor, prior to the completion of the drug and alcohol assessment and weekly via a review of counselor case management logs, will ensure that clients rights have been reviewed and there is documented clinical acknowledgement in the chart. We are implementing an electronic monitoring/tracking system that involves staff, Clinical Supervisor, and Quality Assurance Officer which will alert to all involved the required completion dates of the documentation. The Facility Director is responsible for this action. Additionally, the Quality Assurance Officer will monitor the implementation of this procedure during compliance reviews of charts.
Completion date: 11/1/2025
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which should include a familiarization with the project's policies, in three of five applicable client records reviewed.
Client #5 was admitted on January 7, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to project and its policies until September 8, 2025.
Client #6 was admitted on March 4, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to project and its policies until September May 13, 2025.
Client #7 was admitted on December 17, 2024 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to project and its policies until September 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
4. 1853: 709.91(b)(2)(i) Licensure Intake and admission:
Upon admission to the program, all clients will meet in-person with their counselor to document orientation to the project which includes, but is not limited to, a familiarization to the following: (i) project policies. The Clinical Supervisor will review all client records following admission to the program to ensure that clients are fully oriented to the program and that the orientation is documented in the clinical record. Quality Assurance Officer will monitor the implementation of this procedure during compliance reviews of charts.
Completion date: 11/1/2025
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which should include a familiarization with the project's hours of operation, in three of five applicable client records reviewed.
Client #5 was admitted on January 7, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its hours of operation until September 8, 2025.
Client #6 was admitted on March 4, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its hours of operation until May 13, 2025.
Client #7 was admitted on December 17, 2024 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its hours of operation until September 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
5. 1855: 709.91(b)(2)(ii) Licensure Intake and admission:
Upon admission to the program, all clients will meet in-person with their counselor to document orientation to the project which includes, but is not limited to, a familiarization to the following: (ii) hours of operation. The Clinical Supervisor will review all client records following admission to the program to ensure that clients are fully oriented to the program and that the orientation is documented in the clinical record. Quality Assurance Officer will monitor the implementation of this procedure during compliance reviews of charts.
Completion date: 11/1/2025
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which should include a familiarization with the project's fee schedule, in three of five applicable client records reviewed.
Client #5 was admitted on January 7, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its fee schedule until September 8, 2025.
Client #6 was admitted on March 4, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its fee schedule until May 13, 2025.
Client #7 was admitted on December 17, 2024 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its fee schedule until September 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
6. 1857: 709.91(b)(2)(iii) Licensure Intake and admission:
Upon admission to the program, all clients will meet in-person with their counselor to document orientation to the project which includes, but is not limited to, a familiarization to the following: (iii) Fee schedule. The Clinical Supervisor will review all client records following admission to the program to ensure that clients are fully oriented to the program and that the orientation is documented in the clinical record. Quality Assurance Officer will monitor the implementation of this procedure during compliance reviews of charts.
Completion date: 11/1/2025
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to provide client orientation to the project, which should include a familiarization with the services provided by the project in three of five applicable client records reviewed.
Client #5 was admitted on January 7, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its provided services until September 8, 2025.
Client #6 was admitted on March 4, 2025 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its provided services until September May 13, 2025.
Client #7 was admitted on December 17, 2024 and was active at the time of the inspection. There was documentation in the record indicating the client did not receive orientation to the project and its provided services until September 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
7. 1859: 709.91(b)(2)(iv) Licensure Intake and admission:
Upon admission to the program, all clients will meet in-person with their counselor to document orientation to the project which includes, but is not limited to, a familiarization to the following: (iv) Services provided. The Clinical Supervisor will review all client records following admission to the program to ensure that clients are fully oriented to the program and that the orientation is documented in the clinical record. Quality Assurance Officer will monitor the implementation of this procedure during compliance reviews of charts.
Completion date: 11/1/2025
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client and per the facility policy, in five of five applicable client records reviewed.
The facility's policy and procedures manual stated the individual treatment and rehabilitation plans are to be completed within 30 days of admission.
Client #3 was admitted January 7, 2025 and discharged on May 29, 2025. The individual treatment and rehabilitation plan was due to be completed by February 7, 2025; however, the plan was completed on April 2, 2025.
Client #4 was admitted on December 19, 2024 and was discharged on April 14, 2025. There was no documentation of an individual treatment and rehabilitation plan in the record.
Client #5 was admitted on January 7, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by February 7, 2025; however, the plan was completed on July 22, 2025.
Client #6 was admitted on March 4, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by April 4, 2025; however, the plan was completed on May 13, 2025.
Client #7 was admitted on December 17, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by January 17, 2025; however, the plan was completed on September 16, 2025.
This is a repeat citation from the September 25, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per JFK's facility policy and procedure manual, all clients who are active in treatment will have their individual treatment and rehabilitation plan completed within 30 days of admission. Additionally, all clients who are active in treatment will have their case consultation notes completed every 90 days. The Clinical Supervisor will perform a weekly review of counselor case management logs to identify all upcoming treatment plans (including new admissions) and case consultation notes. Counselors will be instructed to complete these treatment plans and case consultation notes prior to expiration. To ensure that these timelines are adhered to, Quality Assurance will monitor the completion of these documents and compliance of this practice during chart reviews.
Completion Date: 11/1/2025
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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 two of four applicable client records reviewed.
Client #1 was admitted on March 21, 2022 and was discharged on August 18, 2025. Throughout the client's treatment episode, there was only one documented treatment plan update, which was completed on June 15, 2024.
Client #2 was admitted on April 23, 2024 and was discharged on August 14, 2025. Throughout the client's treatment episode, there was only one documented treatment plan update, which was completed on March 3, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
9. 1883 : 709.92(b) Licensure Treatment and rehabilitation services:
All clients who are active in treatment will have their treatment plans reviewed and updated at least every 60 days. The Clinical Supervisor will perform a weekly review of counselor case management logs and identify all upcoming treatment plans in supervision. Counselors will be instructed to complete these treatment plan updates prior to expiration. This will also be a topic of each staff meeting to reinforce the importance of maintaining current treatment plan documentation for all active clients. Quality Assurance will monitor the completion and compliance of this practice during chart reviews.
Completion Date: 11/1/2025
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