INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 23, 2025 through September 24, 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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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician conducted an initial face-to-face with the individual to determine current dependency upon a narcotic drug, prior to the administration of a maintenance agent, in one of three applicable patient records reviewed.
Patient #1 was admitted on November 20, 2024 and was active at the time of the inspection. The initial dose of maintenance medication was administered on November 20, 2024; however, the initial face-to-face meeting with the physician was conducted and documented on December 12, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP Plan of Correction
M059:
Effective immediately, JFK's MATP physician will complete a face- to-face physical examination to determine whether a person is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for methadone maintenance treatment. Our physician will document the basis for the determination of current dependency and evidence of a 1- year history of addiction in the person's electronic health record.
The Clinical Supervisor is responsible for ensuring JFK's compliance with this standard.
Date: October 1, 2025
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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the narcotic treatment program failed to secure a personal history from the patient within the first week of admission in two of four applicable patient records reviewed.
Patient #1 was admitted on November 20, 2024 and was active at the time of the inspection. The personal history from the patient was due to be completed no later than November 27, 2024; however, the history was completed on December 3, 2024.
Patient #2 was admitted on May 29, 2025 and was active at the time of the inspection. The personal history from the patient was due to be completed no later than June 5, 2025; however, the history was completed on August 18, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
M071:
Effective immediately, a personal history will be completed on the same day of the person's face to face physical examination. After the physical examination, the person is entered into Methasoft for methadone administration. At that time, a personal history will be completed in our electronic health record. Therefore, all personal histories will be completed well within one week after the physical examination.
The Clinical Supervisor will ensure compliance with this standard.
Date: 10/1/2025
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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 narcotic treatment program failed to obtain an informed, voluntary, and written patient consent prior to the administration of an agent in two of four applicable patient records reviewed.
Patient #1 was admitted on November 20, 2024 and was active at the time of the inspection. The initial dose of maintenance medication was administered on November 20, 2024; however, the informed consent was signed and dated by the patient on December 12, 2024.
Patient #7 was admitted on December 30, 2024 and was discharged on March 10, 2025. The initial dose of maintenance medication was administered on December 31, 2024; however, the informed consent was signed and dated by the patient on January 2, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
M095:
Effective immediately, JFK will obtain an informed, voluntary, written consent (containing all required elements) before methadone is administered to the person entering treatment. This applies to new admissions as well as readmissions when a record has been closed and reopened.
The Clinical Supervisor is responsible for ensuring compliance with this standard.
Date: 10/1/2025
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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 three applicable patient records reviewed.
Patient #6 was admitted on December 30, 2024 and was discharged on March 10, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the patient ' s date of admission and of the date the initial dose given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
M199:
JFK will revise its written policy and procedure to include clients who arrive from hospital-based drug/alcohol programs as well as outpatient MATPs. Hospital-based MATPs will receive same day written notification of the person's admission and the date of their initial dose given by JFK.
The Clinical Supervisor is responsible for revising our policy/procedure and ensuring compliance with this standard.
Date: 10/1/2025
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and also reviewed, dated, and signed by the medical director in one of four applicable patient records reviewed.
Patient #5 was admitted on December 24, 2013 and was discharged on December 12, 2024. The annual evaluation of the patient's status was completed by the counselor on November 4, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director 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
M267:
Effective immediately, all client annual evaluations of his/her status will be completed by the person's counselor and also reviewed, dated, and signed by the medical director.
The Clinical Supervisor will review all annual evaluations as they are completed in our electronic record system to ensure compliance.
Date: 10/1/2025
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