INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ponessa Behavioral Health 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 one personnel record, the facility failed to ensure that 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 Department approved curriculum.
Employee #6 was hired as the receptionist on December 16, 2019, and was still in the position at the time of the inspection. The employee was due to have the communicable disease training no later than December 16, 2021, however there was no documentation that the required 4 hours of TB/STD were completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SUD Director will review with all clinical and non-clinical staff the requirement to complete TB/STD training and HIV training within 1 year for clinical staff and 2 years for non-clinical staff. SUD director will ensure all required trainings are completed ASAP. SUD Director will review all training plans by 7/4/2025 and then quarterly to ensure staff are on track to complete required trainings by due date. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, facility's staff schedules and the Staffing Requirement Facility Summary Report (SRFSR), the project failed to ensure that at least a sufficient number of staff persons trained in CPR and first aid was onsite during the project's hours of operation.
The facility's hours of operation are Monday - Thursday 8:00am - 8:00 pm and Fridays 8:00 am - 5:00pm. There were no staff members with a current CPR/First Aid Certificate between the hours of 8:00 AM and 8:00 PM on Mondays and Wednesdays, and 8:00 AM and 5:00 PM on Fridays.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
SUD Director will review with all clinical staff the requirement to have at least a sufficient number of staff persons training in CPR and first aid onsite during the hours of operation. SUD Director will ensure there is a sufficient number of staff trained by 7/4/2025 and review the status of all certifications on an annual basis. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for fiscal year 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SUD Director will review with CEO the requirements to provide a copy of the obtained financial audit from a Certified Public Accountant at the time of the DDAP audit by 6/27/2025. SUD Director will ensure a copy of the financial audit for the previous fiscal year is provided by the due date of all pre-submission paperwork. SUD Director will also applied for financial exemption on 6/25/2025. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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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 which included the purpose of the disclosure in two out of seven records reviewed.
Client #3 was admitted on August 01, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to the funder, signed and dated August 01, 2024, did not include the purpose of disclosure.
Client #4 was admitted on July 24, 2024, and discharged February 12, 2025. An informed and voluntary consent from the client for the disclosure of information to the funder, signed and dated July 24, 2024, did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed the requirement to obtain a consent to release information prior to releasing information with all clinical staff on 6/26/2025. SUD Clinical Director is requiring staff to review all funding consents by 8/1/2025 to ensure the purpose for the funder is clearly documented. SUD Director will complete chart audits to ensure all client charts are updated by 8/5/2025. Director will complete quarterly chart audits to ensure this deficiency does not happen again. |