INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29, 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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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.These findings were reviewed with project 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 Tax Return from a Certified Public Accountant at the time of the DDAP audit by 6/4/2025. SUD Director will ensure a copy of the tax return for the previous fiscal year is provided by the due date of all pre-submission paperwork. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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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 record which included the dated signature of the client in one out of seven records reviewed.Client #3 was admitted on September 16, 2024 and was still an active client. There was an informed and voluntary consent in the client record dated September 16, 2024, that did not include the signature of the client. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SUD Director will review with all staff on 6/4/2025 that all client signatures on all informed and voluntary consents must be signed large enough to be validated by an unknown party. SUD Director will also remind staff that all informed and voluntary consents must have a signature from the client. SUD Director and SUD Clinical Supervisor will review all charts to ensure all voluntary and informed consents have a verifiable signature of the client in all active charts by 6/6/2025 and conduct monthly audits to ensure these signatures are captured in the future. |