D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.

PONESSA BEHAVIORAL HEALTH
15 SOUTH NINTH STREET
LEBANON, PA 17042

Inspection Results Overview Definitions Surveys Additional Services Search

Survey conducted on 06/18/2025

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on June 18, 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:	Plan of Correction
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.
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.	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 also applied for financial exemption on 6/25/2025.
709.92(c) LICENSURE Treatment and rehabilitation services 709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Observations Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in six out of seven applicable records reviewed. Client #1 was admitted on October 25, 2024, and was still active at the time of the inspection. The individual treatment plan dated November 22, 2024, indicated one individual treatment session weekly. There is no documentation the client received one individual weekly session for the weeks of November 10-16, November 24-30, January 05-11, February 02-08, February 9-15, February 16-22, February 23-March 1, April 06-12, May 4-10, May 11-17, May 18-24, and May 25-31. Client #2 was admitted on June 25, 2024 and was still active at the time of the inspection. The individual treatment plan dated July 23, 2024, indicated one individual treatment session weekly. There is no documentation the client received one individual weekly session for the weeks of July 28-August 3, August 11-17, August 18-24, October 27-November 2, December 8-14, December 15-21, December 29-January 4, January 5-11, January 12-18, February 16-22, March 9-15, March 23-29, May 04-10, May 11-17, May 18-24. Client #3 was admitted on October 21, 2024 and was still active at the time of the inspection. The individual treatment plan dated November 19, 2024, indicated one individual treatment session weekly. There is no documentation the client received one individual weekly session for the weeks of November 24-30, December 1-7, December 8-14, December 15-21, December 22-28, December 29-January 4, January 5-11, February 2-8, February 9-15, February 16-22, March 2-8, March 9-15, March 16-22, March 23-29, March 30-April 5, April 13-19, April 27-May 03, May 04-10, May 18-24, May 25-31, June 01-07, and June 08-14. Client #4 was admitted on August 08, 2024 and discharged on December 13, 2024. The individual treatment plan dated on August 18, 2024, indicated one individual treatment session weekly. There is no documentation the client received one individual weekly session for weeks of August 18-24, August 25-31, September 01-07, September 08-14, September 15-21, September 22-28, September 29-October 05, October 13-19, October 20-26, November 10-16, and November 17-23. Client #5 was admitted on October 23, 2024 and discharged on January 31, 2025. The individual treatment plan dated November 22, 2024 indicated one individual treatment session weekly. There is no documentation the client received one individual weekly session for the weeks of December 22-28 and December 29-January 04. Client #6 was admitted on May 07, 2024 and discharged on November 7, 2024. The individual treatment plan dated May 21, 2024, indicated one individual treatment session weekly. There is no documentation the client received one individual weekly session for the weeks of May 26- June 01, June 02-08, July 07-13, and July 21-27. These findings were reviewed with facility staff during the licensing process.	Plan of Correction SUD Director will review with all staff on 6/24/2025 that all clients but be receiving counseling services according to the frequency noted on their individual treatment plan. SUD Director will complete chart audits to ensure are clients are scheduled or contacted to be scheduled by 6/27/2025. SUD Director and SUD Supervisor will complete chart audits on all clients on a monthly basis to ensure clients are being seen in the appropriate frequency so that this does not happen in the future.