INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on October 7, 2025 through October 9, 2025 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(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 Requirement 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 topics training within the regulatory time frame in one of one applicable personnel records reviewed.
Employee #3 was hired as a counselor on October 23, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than October 23, 2024. At the time of the inspection, there was no documentation in the personnel record documenting that the TB/STD training was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health reviewed this citation with the Counseling Staff on 10/23/2025 & 10/24/2025.
1) All newly hired counseling staff will now be required to obtain the required DDAP trainings within 10 months of employment.
In order to ensure continued compliance with this regulation, the Director of Behavioral Health will audit each counselor's training history on a monthly basis to ensure they meet the DDAP training requirement within 12 months of hire.
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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 January 2024 through December 2024 training year, in one of two applicable personnel records reviewed.
Employee #4 was hired as a counselor on March 27, 2023. The personnel record documented 19 hours of annual training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Counseling staff on 10/23/2025 & 10/24/2025 to review this citation.
All employees are now mandated to obtain their 25 hours of annual training by 10/31 of each year.
In order to ensure future compliance, the Director of Behavioral Health has developed a Training Audit Form to closely monitor each Counselor's annual training hours on a monthly basis. This monthly monitoring will assist in identifying any counselor short on their annual training hours. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's September 2024 through August 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided indicating fire drills were conducted during the months of September 2024 through February 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health discussed this citation with the current Facilities Director on 10/21/2025.
1) The current Facilities Director replaced the former Director and fully understands the importance of conducting monthly fire drills.
In order to ensure future compliance of this standard, the following will occur effective immediately:
1) The Facilities Director is required to present the actual fire drill documentation at the monthly Patient Safety Committee meetings for the Committee's review.
2) The documentation of the fire drills will also be presented to the quarterly Safety Committee for their information and review.
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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 obtain an initial drug-screen urinalysis was submitted and approved by the Department for the September 27, 2023 and September 13, 2024 annual licensing inspections. Failing to obtain an initial drug-screen urinalysis was again found to be a deficiency in the October 7, 2025 through October 9, 2025 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Admissions Intake Staff on 10/24/2025 to review this repeat citation.
Staff was reminded that the initial drug screen must be obtained at time of intake and document on the medical record.
Because this is a repeat citation, the CEO and Director of Behavioral Health will now receive the results from the Performance Improvement Coordinator after she conduct chart reviews on a monthly basis to ensure the initial UDS is done and maintained on the medical record. If needed, disciplinary action will be taken on those employees who are non-complaint with this requirement.
The Performance Improvement Coordinator will also forward the results to the Performance Improvement Committee on a quarterly basis.
The |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, which is to include their name, address, date of birth, emergency contact and other identifying data, in two of nineteen patient records reviewed.
Patient #15 was admitted to the inpatient non-hospital detoxification activity on June 13, 2025 and discharged on June 18, 2025. There was no verification documentation, in the record, of the patient's emergency contact at the time of the inspection.
Patient #19 was admitted to the inpatient non-hospital detoxification activity on July 25, 2025 and discharged on July 30, 2025. There was no verification documentation, in the record, of the patient's emergency contact at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Admissions Intake Staff on 10/21/2025 to review this citation.
After the meeting the Admissions Intake Staff acknowledged fully understanding the importance of the verification of an individual's identity to include, name, address, date of birth, emergency contact and other identifying data.
In order for Kensington Hospital to ensure future compliance, the Performance Improvement Coordinator will audit medical records monthly to ensure the verification of an individual's identity is documented to include, name, address, date of birth, emergency contact and other identifying data.
The results from this monthly review will be presented to the Performance Improvement Committee at their quarterly meetings. |
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 narcotic treatment program failed to document, prior to administration of an agent, the results of a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug in two of nineteen applicable patient records reviewed.
Patient # 2 was admitted to the inpatient hospital activity on September 26, 2025 and was active at the time of inspection. The face-to-face determination was documented in the record on September 30, 2025; however, the patient was given their initial dose of medication on September 27, 2025.
Patient # 5 was admitted to the inpatient hospital activity on January 23, 2025 and was discharged on January 31, 2025. The face-to-face determination was documented in the record on February 6, 2025; however, the patient was given their initial dose of medication on January 23, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director discussed this citation with the Medical Staff on 10/21/2025 & 10/22/2025. The Medical Director reiterated the requirement to conduct and document a face-to-face determination of whether the individual is currently physiologically dependent upon a narcotic.
In order to ensure future compliance of this standard, the Performance Improvement Coordinator will review medical records on a monthly basis to determine if in fact a face to face determination is conducted and documented on the medical chart.
Monthly results will be forwarded to the Medical Director monthly and to the Performance Improvement Committee on a quarterly basis.
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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 six of nineteen applicable patient records reviewed.
Patient #1 was admitted to the inpatient hospital activity on September 26, 2025 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 #15 was admitted to the inpatient non-hospital detoxification activity on June 13, 2025 and was discharged on June 18, 2025. There was no onsite photograph documented in the record at the time of the inspection.
Patient #19 was admitted to the inpatient non-hospital detoxification activity on July 25, 2025 and was discharged on July 30, 2025. There was no onsite photograph documented in the record at the time of the inspection.
Patient #22 was admitted to the inpatient non-hospital activity on September 26, 2025 and was active at the time of the inspection. There was no onsite photograph documented in the record at the time of the inspection.
Patient #24 was admitted to the inpatient non-hospital activity on September 22, 2025 and was active at the time of the inspection. There was no onsite photograph documented in the record at the time of the inspection.
Patient #25 was admitted to the inpatient non-hospital activity on December 13, 2024 and was discharged on January 11, 2025. 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 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Admissions Intake Staff to review this citation.
After the meeting, the Admissions Intake Staff acknowledged the importance of maintaining a photograph, which is to also include the patient's name and date of birth in the medical record.
In order to ensure future compliance with this standard, monthly charts reviews will be conducted by the Performance Improvement Coordinator.
The Performance Improvement Coordinator will report the monthly results to the Performance Improvement Committee on a quarterly basis. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document the completion of an initial drug-screening analysis for each prospective patient in one of nineteen applicable patient records reviewed.
Patient #22 was admitted to the inpatient non-hospital activity on September 26, 2025 and was active at the time of the inspection. The physician prescribed maintenance medication to the patient on September 27, 2025; however, there was no initial urinalysis drug-screen documented in the record prior to the patient's first dose.
This is a repeat citation from the September 27, 2023 and September 13, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/24/2025, the Director of Behavioral Health held a meeting with the Counselors to review this citation.
The Director reiterated the requirement that the initial drug screen must be completed and documented on the medical chart for all patients admitted to Kensington Hospital's Behavioral Health Unit. The Counselors acknowledged full understanding of this requirement at time of the meeting.
Monthly chart reviews will be conducted by the Performance Improvement Coordinator (to check that initial drug screens are completed and documented on the medical record).
Because this is a repeat citation from two (2) previous inspections, the CEO and Director of Behavioral Health will receive results from the review in real time to better monitor compliance of this standard.
The PI Coordinator will continue to forward the results to the Performance Improvement Committee on a quarterly basis.
The PI Coordinator will also forward the results to the Performance Improvement Committee on a quarterly basis.
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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 narcotic treatment program failed to ensure the narcotic treatment physician determined the initial dosage level for patients in six of nineteen applicable patient records reviewed.
Patient #5 was admitted to the inpatient hospital activity on January 23, 2025 and was discharged on January 31, 2025. There was documentation in the record indicating that the initial medication dose was determined and ordered by a certified registered nurse practitioner, not the narcotic treatment physician.
Patient #16 was admitted to the inpatient non-hospital detoxification activity on February 13, 2025 and was discharged on February 18, 2025. There was documentation in the record indicating that the initial medication dose was determined and ordered by a certified registered nurse practitioner, not the narcotic treatment physician.
Patient #19 was admitted to the inpatient non-hospital detoxification activity on July 25, 2025 and was discharged on July 30, 2025. There was documentation in the record indicating that the initial medication dose was determined and ordered by a certified registered nurse practitioner, not the narcotic treatment physician.
Patient #22 was admitted to the inpatient non-hospital activity on September 26, 2025 and was active at the time of the inspection. There was documentation in the record indicating that the initial medication dose was determined and ordered by a certified registered nurse practitioner, not the narcotic treatment physician.
Patient #23 was admitted to the inpatient non-hospital activity on October 2, 2025 and was active at the time of the inspection. There was documentation in the record indicating that the initial medication dose was determined and ordered by a certified registered nurse practitioner, not the narcotic treatment physician.
Patient #27 was admitted to the inpatient non-hospital activity on June 24, 2025 and was discharged on June 25, 2025. There was documentation in the record indicating that the initial medication dose was determined and ordered by a certified registered nurse practitioner, not the narcotic treatment physician.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director addressed this citation with the Medical Staff at the Executive Committee meeting which included the CRNP's on 10/23/2025.
Since the initial medication dosage must be determined and ordered by the NTP physician, the CRNP's were instructed they must obtain a verbal order from the NTP physician if it is the initial medication dosage for the patient.
In order to ensure future compliance, the Performance Improvement Coordinator will conduct monthly chart reviews to ensure the CRNP's are obtaining the verbal order from the NTP physician if it is the patient's initial medication dosage.
Results from the monthly charts reviews will be forwarded to the Medical Director for her review.
Results from the monthly monitor will also be forwarded to the Performance Improvement Committee for their review. |
711.62(c)(2) LICENSURE Informed & Voluntary Consent
711.62. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven applicable client records reviewed.
Client #15 was admitted to the inpatient non-hospital detoxification activity on June 13, 2025 and was discharged on June 15, 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Counseling Staff on 10/24/2025 to review the citation.
The Counseling staff were reminded they must obtain the voluntary consent of the patient for the disclosure of information.
In order to ensure continued compliance with this standard, the Performance Improvement Coordinator will conduct monthly record chart audits to be sure the voluntary consents for the disclosure of information are signed by the patient and maintained on the medical record.
The results from the monthly chart audits will be presented to the Performance Improvement Committee on a quarterly basis.
Results of the |
711.62(c)(2)(i) LICENSURE Name of Person/agency/organization
711.62. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The 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 a disclosure was to be made to on release of information forms in one of seven applicable client records reviewed.
Client #17 was admitted to the inpatient non-hospital detoxification activity on June 24, 2025 and was discharged on June 30, 2025. There was a blank release of information form signed and dated by the client on June 24, 2025; however, the name of the person, agency or organization to whom the disclosure was to be made was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health reviewed this citation with the Counseling Staff on 10/24/2025.
The Director reiterated the importance of documenting complete information on the Release of Information form, which must include: name of the person, agency or organization to whom a disclosure is made to on the Release of Information form.
Monthly chart reviews will be conducted by the Hospital's Performance Improvement Coordinator to ensure future compliance is made.
The results from the monthly chart reviews will be forwarded to the Performance Improvement Committee on a quarterly basis. |
711.62(c)(2)(iii) LICENSURE Purpose of Disclosure
711.62. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure of information on consent to release of information forms in two of seven applicable client records reviewed.
Client #17 was admitted to the inpatient non-hospital detoxification activity on June 24, 2025 and was discharged on June 30, 2025. There was a blank release of information form signed and dated by the client on June 24, 2025; however, the purpose of the disclosure was not documented on the release form.
Client #19 was admitted to the inpatient non-hospital detoxification activity on July 25, 2025 and was discharged on July 30, 2025. There was a release of information form for an outside individual signed and dated by the client on July 25, 2025; however, the purpose of the disclosure was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Counseling staff on 10/24/2025 to review this citation.
The Counseling staff were reminded to document the purpose of the disclosure of information on the consent to Release of Information form.
To ensure future compliance, the Performance Improvement Coordinator will audit medical records on a monthly basis to ensure the counselors are documenting the purpose of the disclosure of information on the consent to Release of Information form.
The results of the monthly audits will be presented to the Hospital's Performance Improvement Committee on a quarterly basis. |
711.62(c)(3) LICENSURE Client's copy of consent
711.62. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in one of seven applicable client records reviewed.
Client #17 was admitted to the inpatient non-hospital activity on June 24, 2025 and was discharged on June 30, 2025. There was a blank release of information form signed and dated by the client on June 24, 2025; however, there was no documentation, in the record, indicating a copy of the consent was offered to the client. Additionally, there was a release of information form to the funding source signed and dated by the client on June 24, 2025; however, there was no documentation, in the record, indicating a copy of the consent was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/24/2025, the Director of Behavioral Health met with the Counseling staff to remind them to offer the patient a copy of the patient's consent to release information form.
Documentation must be maintained on the medical record indicating a copy of the consent was offered to the patient.
The Performance Improvement Coordinator will review medical records on a monthly basis to ensure the counselors are:
1) Offering the patient a copy of the their consent to release information form;
2) Documentation is maintained on the medical record indicating a copy of the consent was offered to the patient.
The results of this monthly review will be forwarded to Kensington Hospital's Performance Improvement Committee at their quarterly meetings. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 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 15 days, for client treatment regimens that are less than 30 days, in one of one applicable client record reviewed.
Client #25 was admitted to the inpatient non-hospital activity on December 13, 2024 and was discharged on January 11, 2025. The individual treatment and rehabilitation plan was completed on December 16, 2024 and the first update was due to be completed no later than December 31, 2024; however, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health resumed meetings with the Counseling Staff on 10/27/2025 to review this citation.
Counselors were reminded they must review and update the patients' treatment and rehabilitation plans every 15 days, for client treatment regimens that are less then 30 days.
In order to ensure continued compliance, the Performance Improvement Coordinator will review medical charts which will ensure the counselors are updating the patient's treatment and rehabilitation plans every 15 days, for client treatment regimens that are less than 30 days.
The results of the monthly chart reviews will be forwarded to the Hospital's Performance Improvement Committee on a quarterly basis. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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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 one of seven applicable client records reviewed.
Client #28 was admitted to the inpatient non-hospital activity on June 16, 2025 and was discharged on June 24, 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/24/2025, the Director of Behavioral Health met with the Counseling Staff to review this citation.
Counselors were reminded to obtain a written informed and voluntary consent from the patient for the disclosure of information.
The Performance Improvement Coordinator will conduct medical record review on a monthly basis to ensure this standard is being followed.
The Performance Improvement Coordinator will present the results of the monthly medical record reviews to the Hospital's Performance Improvement Committee at their quarterly meetings. |
711.53(c)(2)(i) LICENSURE Person/Agency/Org to Whom Disclosure Made
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency, 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 a disclosure was to be made to on a release of information form in one of seven applicable client records reviewed.
Client #27 was admitted to the inpatient non-hospital activity on June 24, 2025 and was discharged on June 25, 2025. There was a blank release of information form signed and dated by the client on June 24, 2025; however, the name of the person, agency or organization to whom the disclosure was to be made was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Behavioral Health Director met with the Counselors on 10/24/2025 to remind them they must document the name of the person, agency or organization to whom a disclosure is to be made to on the Release of Information form.
In order to ensure future compliance with this standard, the Performance Improvement Coordinator will conduct monthly audits on medical charts to ensure the counselors are documenting the following information:
1) Name of the Person
2) Agency or organization to whom a disclosure is to be made to on the Release of Information form.
The Performance Improvement Coordinator will present the results of the monthly audits to the Hospital's Performance Improvement Committee on a quarterly basis. |
711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a release of information form in one of seven applicable client records reviewed.
Client #27 was admitted to the inpatient non-hospital activity on June 24, 2025 and was discharged on June 25, 2025. There was a blank release of information form signed and dated by the client on June 24, 2025; however, there was no purpose of the disclosure documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/24/2025, the Director of Behavioral Health met with the Counseling Staff to review this citation.
At this time, the Counselors were reminded to document the purpose of the disclosure on the Release of Information form.
The Performance Improvement Coordinator will conduct monthly chart reviews to ensure the counselors are indeed documenting the purpose of the disclosure on the Release of Information forms.
The Hospital's Performance Improvement Committee will received the results of the monthly chart reviews on this topic at their quarterly meeting. |
711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent was offered to the client in one of seven applicable client records reviewed.
Client #27 was admitted to the inpatient non-hospital activity on June 24, 2025 and was discharged on June 25, 2025. There was a blank release of information form signed and dated by the client on June 24, 2025; however, there was no documentation, in the record, indicating the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/24/2025, the Director of Behavioral Health met with the Counseling staff to review this citation.
Staff were reminded they must offer the patient a copy of their Consent to Release Information form. Documentation must also be maintained on the medical record indicating a copy the consent was offered to the patient.
The Performance Improvement Coordinator will audit medical charts monthly and report the findings to the Performance Improvement Committee at their quarterly meetings. |
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 decision to involuntarily terminate the client's treatment at the project, which is to also include the reason for termination, in one of one applicable client record reviewed.
Client #28 was admitted to the inpatient non-hospital activity on June 16, 2025 and was administratively discharged on June 24, 2025. There was no documentation in the record indicating the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Counseling Staff on 10/27/2025 to review this citation.
The Counselors were reminded they must notify the patient, in writing, and document in the medical record that the patient was notified (in writing) of Kensington Hospital's decision to involuntarily terminate the patient's inpatient treatment as well as the reason for the termination of treatment.
Kensington Hospital's Performance Improvement Coordinator will conduct monthly chart reviews on patients involuntarily terminated from treatment to ensure the counselors are:
1) Notifying the patient (in writing) of his/her involuntary termination from treatment and the reason why they were terminated.
2) Documenting on the medical record that they notified the patient (in writing) of the termination from treatment and the reason why they were terminated.
The Performance Improvement Coordinator will then report the results of the monthly chart review to the Performance Improvement Committee on a quarterly basis. |
710.22(c) LICENSURE Patient Management Services
§ 710.22. Patient management services.
(c) The service staff shall develop a written patient follow-up policy.
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Observations
Based on a review of patient records, the facility failed to follow their written patient follow-up policy in one of one applicable patient records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified after a patient is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Patient #11 was admitted to the inpatient hospital detoxification activity on March 18, 2025 and was discharged against medical advice on March 19, 2025. There was no documentation in the record indicating the emergency contact was notified of the patient's discharge as of the date of the inspection.
This is a repeat citation from the September 13, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held between the Director of Behavioral Health and the Counseling staff to review this citation. The Counseling staff must ensure they notify the emergency contact after a patient is discharged AMA from the Hospital.
In order to ensure future compliance monthly chart reviews will be conducted by the Performance Improvement Coordinator and the results forwarded to the Performance Improvement Committee on a quarterly basis. |
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 failed to ensure treatment and rehabilitation plans were reviewed and updated at least every fifteen days in three of three applicable patient records reviewed.
Patient #4 was admitted to the inpatient hospital activity on February 3, 2025 and was discharged on March 7, 2025. The individual treatment plan was completed on February 4, 2025 and the first update was due no later than February 19, 2025; however, the update was not completed prior to discharge.
Patient #6 was admitted to the inpatient hospital activity on October 25, 2024 and was discharged on November 21, 2024. The individual treatment plan was completed on October 29, 2024 and the first update was due no later than November 13, 2024; however, the update was not completed prior to discharge.
Patient #7 was admitted to the inpatient hospital activity on April 18, 2025 and was discharged on May 23, 2025. The individual treatment plan was completed on April 20, 2025 and the first update was due no later than May 5, 2025; however, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This citation was reviewed at a meeting on 10/24/2025 between the Director of Behavioral Health and the Counselors.
Staff discussed the fact treatment and rehabilitation plans must be reviewed and updated at least every 15 days.
In order to ensure compliance, medical records will be audited by the Performance Improvement Coordinator on a monthly basis.
The PI Coordinator will then present the results from the monthly audits to the Performance Improvement Committee on a quarterly basis. |