INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2026 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 provide business tax returns for the previous fiscal year. Per the waiver granted on July 10, 2025, in lieu of an independent public accountant for an annual audit of financial activities associated with the project ' s drug and alcohol services, the project would make available its business tax returns. The project refused to provide this information.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director will review with CEO the requirement to provide business tax returns for the previous fiscal year. SUD Director will ensure a copy of the tax return will be provided by the due date of all pre-submission paperwork |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #2 was admitted on March 27, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 3, 2026 and an update was due no later than June 3, 2026; however, it was not completed until June 5, 2026.
Client #3 was admitted on November 4, 2025 and was still active at the time of the inspection. A treatment plan update was completed on January 9, 2026 and an update was due no later than March 9, 2026; however, it was not completed until March 16, 2026.
Client #7 was admitted on August 6, 2025 and was discharged on February 6, 2026. A treatment plan update was completed on October 17, 2025 and an update was due no later than December 17, 2025; however, it was not completed until December 19, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical director reviewed will all clinicians the requirement to complete all txplan updates within 60 days in supervision on 6/30/2026. Clinicians were reminded of the importance of utilizing their client lists to show when items are due and using the "highlight" function to serve as a reminder. Clinicians were also educated on the "inactive treatment plan widget" in the EHR system. Clinicians were also reminded that treatment plan updates can be made when it is due even if the client is not present and reviewed at the next session. Clinicians were also reminded that the clinician can sign off on a treatment plan before it is reviewed with the client. Clinicians were reminded that the start date of the treatment plan is reflected by the date of their signature. Clinical Supervisor will conduct chart audits ongoing for all active and new clients and review to ensure this requirement is being met by 7/15/2026. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission for the first year.
Client #1 was admitted on March 9, 2026 and was still active at the time of the inspection. A case consultation was due no later than June 9, 2026; however, it was not completed until June 23, 2026.
Client #5 was admitted on admitted on September 24, 2025 and discharged on March 29, 2026. A case consultation was due no later than December 24, 2025; however, it was not completed until December 30, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
SUD Director reviewed with all clinical staff on 7/1/2026 that all case consultations must be completed at minimum every 90 days for the first year and then annually after that. SUD Director and Clinical supervisor will audit all charts by 7/15/2026 to ensure all client charts meet this requirement. Charts will be audited on a quarterly basis to ensure compliance. |