INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The three fire extinguishers in the facility are labeled " Loaner " and are not marked when they were inspected.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SUD Director will review with property maintenance to ensure all fire extinguishers are inspected at minimum every year by 7/1/2026. All fire extinguishers will be inspected and approved by 7/15/2026. SUD Director will meet with property maintenance 1 month prior to all fire extinguisher inspection due dates to ensure an inspection is schedule and to ensure this citation does not happen in the future. |
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 |
709.93(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 November 15, 2025 and was still active at the time of the inspection. A case consultation was due no later than February 15, 2026; however, it was not completed until February 26, 2026.
Client #5 was admitted on August 20, 2025 and discharged on November 24, 2025. A case consultation was due no later than November 20, 2025; however, no case consultation was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
SUD Director will review with all staff the requirement to complete case consults every 90 days for the first year and then annually after that by 7/1/2026. It will also be reviewed that 2 signatures must be captured by the due date to be in compliance by 7/1/2026. SUD Director will review client list spreadsheets to ensure clinicians are up to date on case consults and complete monthly chart audits to ensure this does not happen in the future. |