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 30, 2025 through October 1, 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 Outpatient Treatment Program 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 January 2024 through December 2024 training year, in one of three applicable personnel records reviewed. Employee #4 was hired as a counselor on February 12, 2018. The personnel record documented 24 hours of annual training during the training year reviewed. This is a repeat citation from the September 18, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counseling staff on 10/13/2025 & 10/14/2025 to review this citation.
All staff are now mandated to obtain their 25 hours of annual training by 10/31 of each year.
In order to ensure future compliance, The Clinical Supervisor has developed a Training Audit form to closely monitor each Counselor's annual training hours on a monthly basis.
This monthly monitoring will identify any counselors short on their annual training hours well in advance of the years end in order to obtain additional hours. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 were no fire drills conducted during the months of September 2024 through February 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Facilities Director to review this citation.
1) The current Facilities Director replaced the former Facilities Director and he fully understands the importance of conducting monthly fire drills.
In order to ensure future compliance of this standard, the following will occur:
1) The Facilities Director is required to present the actual fire drill documentation each month to the Patient Safety Committee for the Committee's review.
2) The documentation of fire drills will also be presented to the Safety Committee on a quarterly basis for their review. |
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 November 5, 2019, May 20, 2021, October 21, 2021, October 25, 2022, and October 12, 2023, and September 18, 2024 annual licensing inspections. Failing to obtain an initial drug-screen urinalysis was again found to be a deficiency in the September 30, 2025, through October 1, 2025 licensing inspection.A plan of correction for failing to ensure the narcotic treatment physician reviewed the dosage level at least twice a year, with each being at least 2 months apart, was submitted and approved by the Department for the October 12, 2023, and September 18, 2024 annual licensing inspections. Failing to ensure the narcotic treatment physician reviewed the dosage level at least twice a year was again found to be a deficiency in the September 30, 2025, through October 1, 2025 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 October 12, 2023 and September 18, 2024 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the September 30, 2025, through October 1, 2025 licensing inspection.This is a repeat citation from the October 25, 2022, October 12, 2023, and September 18, 2024 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director reviewed the following repeat citation with the NTP's at the Executive Committee Meeting of the Medical Staff on 10/21/2025.
1) NTP reviews the dosage level at least twice a year, with each being at least 2 months apart.
The PI Coordinator will continue to conduct monthly chart reviews on this issue and now will report results directly to the Medical Director. Medical Director will review results and if necessary, disciplinary action will be taken against NTP's who are non-compliant in completing the client's review of dosage level at least 2 x a year, 2 months apart.
The Medical Director also met with the Counseling Staff on the following repeat citations on 10/22/2025:
1) An initial drug-screen urinalysis is obtained and documentation is made on the medical record
2) Treatment plan updates must be completed at least every 60 days.
On both citations, the Medical Director is now reviewing all results from the Performance Improvement Study on a monthly basis to ensure there is full compliance.
If necessary, disciplinary action will now be taken against those counselor not achieving full compliance in both requirements stated above.
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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 documentation of their name, address, date of birth, emergency contact, and other identifying data in one of four applicable patient records reviewed. Patient #3 was admitted on March 4, 2025 and was discharged on September 11, 2025. There was no documentation of the patient's emergency contact in the record 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 Clinical Supervisor met with the Admissions Intake Staff on 10/14/2025 to discuss this citation and the plan of correction.
After the meeting, the Admissions Intake Staff acknowledged to fully understanding the importance of verifying the individual's identity, which is to include documentation of their name, address, date of birth, emergency contact, and other identifying data.
In order to ensure future compliance the Performance Improvement Coordinator will review medical records on a monthly basis to ensure the individual's identify is documented on the record which will include client's name, date of birth, emergency contact and other identifying data.
Results from the monthly chart reviews will be presented 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 complete an initial drug-screening analysis for each prospective patient in two of four applicable patient records reviewed. Patient #3 was admitted on March 4, 2025 and was discharged on September 11, 2025. The physician prescribed maintenance medication to the patient on March 4, 2025. The first urinalysis drug-screen documented in the record was completed on March 10, 2025, which was after the patient's first dose.Patient #7 was admitted on April 22, 2025 and was active at the time of the inspection. The physician prescribed maintenance medication to the patient on April 22, 2025. The first urinalysis drug-screen documented in the record was completed on April 24, 2025, which was after the patient's first dose.This is a repeat citation from the November 5, 2019, May 20, 2021, October 21, 2021, October 25, 2022, October 13, 2023, and September 18, 2024 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed this citation with the Admissions Intake on 10/14/2025.
The Admission Intake Worker will send clients for UDS prior to admission, re-admission or re-instatement.
Narcotic Treatment Physician and Intake Worker will not begin client's admission to the Program without completion of the initial UDS.
In order to ensure future compliance, the Clinical Supervisor will monitor the status of the admissions to the Program on a daily basis.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician reviewed the dosage levels at least twice a year, with each review occurring at least 2 months apart, in one of four applicable patient records reviewed. Patient #4 was admitted on July 22, 2022 and was discharged on September 29, 2025. There was documentation that the physician completed dosage level reviews on May 30, 2024 and July 16, 2024 for the 2024 year; however, the dosage level reviews were did not occur at least 2 months apart. This is a repeat citation from the October 12, 2023, and September 18, 2024 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director reviewed this citation with the NTP's at the Executive Committee of the Medical Staff on 10/21/2025.
The NTP's were instructed to review the clients' dosage levels more careful to ensure they are completed at least 2 months apart.
In order to better ensure future compliance, the Medical Director will receive the results from the Performance Improvement Coordinator after she conducts monthly chart reviews monitoring the completion of the of clients' dose levels for:
1) The reviews are completed at least 2 months apart.
The PI Coordinator will now forward these results directly to the Medical Director for her information and review, as disciplinary action will be taken if there is a non-compliance.
Results will also be presented to the Performance Improvement Committee on a quarterly basis. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient, in two of two applicable patient records reviewed. Patient #1 was admitted on July 2, 2024 and was transferred out on February 17, 2025. There was no documentation in the record indicating the receiving narcotic treatment program was provided the date of admission of the patient, dosage level, medical and psychosocial summaries, urinalysis reports or summary, exception requests, and current status of the patient. Patient #2 was admitted on July 3, 2025 and was transferred out on July 15, 2025. There was no documentation in the record indicating the receiving narcotic treatment program was provided the medical and psychosocial summaries and urinalysis reports or summary.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed this citation with the Counseling staff on 10/14/2025 to remind the staff of the required information to be sent to the transferring NTP.
The Clinical Supervisor developed a form to be used by the counselor which now lists all required documents to be sent to the transferring NTP as follows:
1) Admission Date
2) Medical & Psychosocial Summaries
3) Dosage Levels
4) Urinalysis Reports/Summary
5) Exception Requests
6) Current Status of the client
7) Written Consent of the client
In order to ensure future compliance, the Clinical Supervisor will conduct chart reviews on a monthly basis to ensure all required documentation was sent to the transferring NTP.
Results will be provided to the Performance Improvement Committee on a quarterly basis.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of the facility's unusual incident report log, the facility failed to notify the Department within 48 hours of a death or serious injury due to trauma, suicide, medication error or unusual circumstances. On May 12, 2025 and May 15, 2025, the facility was notified of the deaths of three different patients; however, there was no documentation provided indicating these three incidents were reported to the Department as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health met with the Clinical Supervisor to review this citation on 10/13/2025.
The Clinical Supervisor is fully aware to notify the Department within 48 hours of a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
In order to ensure future compliance, the Director of Behavioral Health Services will monitor the incident reports involving any death or serious injury due to trauma, suicide, medication error or unusual circumstances on a daily basis to ensure those incidents are being reported to the Department within 48 hours. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 five of six applicable client records reviewed.Client #3 was admitted on March 4, 2025 and was discharged on September 11, 2025. The individual treatment and rehabilitation plan was completed on March 10, 2025, and the first update was due no later than May 10, 2025; however, the update was completed on May 30, 2025.Client #4 was admitted on July 22, 2022 and was discharged on September 29, 2025. A treatment plan update was completed on October 23, 2024, and the next update was due no later than December 23, 2024; however, the update was completed on January 10, 2025.Client #5 was admitted on February 27, 2017 and was active at the time of the inspection. A treatment plan update was completed on May 21, 2025, and the next update was due no later than July 21, 2025; however, the update was completed on September 10, 2025.Client #6 was admitted on January 3, 2013 and was active at the time of the inspection. A treatment plan update was completed on January 15, 2025, and the next update was due no later than March 15, 2025; however, the update was completed on April 2, 2025. Additionally, the next update was due no later than June 2, 2025; however, the update was completed on June 11, 2025. Also, the next update was due no later than August 11, 2025; however, the update was completed on August 20, 2025.Client #8 was admitted on May 2, 2017 and was active at the time of the inspection. A treatment plan update was completed on November 25, 2024, and the next update was due no later than January 25, 2025; however, the update was completed on April 10, 2025. Additionally, the next update was due no later than June 10, 2025; however, the update was completed on July 10, 2025.This is a repeat citation from the October 12, 2023 and September 18, 2024 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counseling staff on 10/14/2025 to review this citation.
Counselors acknowledged their understanding of this requirement and will updated treatment and rehabilitation plans every 60 days from the admission or re-admission date as well as the annual review.
In order to ensure future compliance, the counselors will conduct a monthly review of their caseload. In addition, the Clinical Supervisor will conduct a chart review on a quarterly basis to ensure the treatment and rehabilitation plans are updated every 60 days from the admission or re-admission date as well as the annual review.
The results of the quarterly review will be presented to the Performance Improvement Committee for their review. |