INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hope's Destiny 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 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of September 2024 - September 2025 fire drills logs, the facility failed to document the amount of time it took for evacuation in the February -September 2025 logs. In addition, in the September 2024 - January 2025 logs, exit route and number of persons in the facility at the time of the drill were not documented.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 13, 2024 annual licensing inspection.
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Plan of Correction
Effective immediately, Hope's Destiny has revised its Fire Drill Log Form to ensure full compliance with §705.28(d)(4). The revised form now includes fields for the date, time, amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered, and confirmation that the fire alarm or smoke detector was operative. The Office Manager will be responsible for conducting and documenting all monthly fire drills, ensuring that every required field is completed immediately after each drill. The Chief Operating Officer will conduct quarterly audits to confirm continued compliance. All staff responsible for fire safety were retrained on November 12, 2025, regarding the updated documentation requirements and DDAP fire safety standards. The facility will be in full compliance with this standard by November 30, 2025, and ongoing monitoring will be maintained thereafter to prevent recurrence of this deficiency. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of September 2024 - September 2025 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills in the February - September 2025 drills. The back door was used in these drills.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny has updated its Fire Drill Log Form to include a designated section specifying that alternate exit routes must be used and documented during monthly fire drills. Effective immediately, the Office Manager will ensure that a different exit route is selected for each drill and recorded on the form. All staff responsible for fire safety were retrained on November 4, 2025, on the revised procedure and the importance of rotating exits to ensure full compliance with §705.28(d)(5). The facility will be in full compliance with this standard by November 30, 2025, and ongoing monitoring will be conducted by the Chief Operating Officer to ensure consistent adherence. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.Client #2 was admitted on April 22, 2025 and discharged on July 1, 2025.Client #7 was admitted on June 2, 2025 and discharged on August 16, 2025.This is a repeat citation from the September 13, 2024 annual licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Chief Operating Officer provided training to all clinical and administrative staff emphasizing that a signed Release of Information for the funding source is mandatory and must be fully completed prior to the start of treatment. The training reinforced that no client information may be released, and no services may be billed, until a valid consent is on record. The Clinical Supervisor will verify the presence of this consent during monthly random chart audits to ensure ongoing compliance. Staff received training on November 6, 2025. The facility will be in full compliance with this standard by November 30, 2025, with continued oversight by the Chief Operating Officer. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not contain that they shall retain civil rights and liberties except as provided by statute and no client may be deprived of a civil right solely by reason of treatment.The finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 13, 2024 annual licensing inspection.
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Plan of Correction
Hope's Destiny has corrected the Client Rights Form to include all language required under §709.30(1)?(6), ensuring that clients are fully informed of their civil rights and liberties, non-discrimination protections, and rights related to accessing and correcting their records. The revised form was implemented immediately and uploaded into the electronic health record system for consistent use. The old form is no longer accessible. The Clinical Supervisor will verify the correct form is being used during weekly chart reviews and conduct monthly random chart audits to ensure continued compliance. The facility will be in full compliance by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights forms given to the client did not contain that the project may not discriminated based on ethnicity, marital status, sexual orientation, handicap and religion. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny has revised its Client Rights Form to include all required language under §709.30(1)?(6), ensuring that clients are fully informed of their rights, including non-discrimination protections related to age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, and religion. The updated form was implemented immediately and uploaded into the electronic health record for consistent use. The old form is no longer accessible. The Clinical Supervisor will verify that the correct form is being used during weekly chart reviews and will conduct monthly random chart audits to ensure continued compliance. The facility will be in full compliance by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not contain that they have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny has revised its Client Rights Form to include all required language under §709.30(1)?(6), ensuring that clients are fully informed of their rights, including their right to inspect their own records and the facility's ability to temporarily remove sections that may be detrimental if presented to the client. The updated form was implemented immediately and uploaded into the electronic health record system for consistent use. The old form is no longer accessible. The Clinical Supervisor will verify that the correct form is being used during weekly chart reviews and will conduct monthly random chart audits to ensure continued compliance. The facility will be in full compliance by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not contain that they have the right to appeal a decision limiting access to their records to the director. This is a repeat citation from the September 13, 2024 annual licensing inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny has revised its Client Rights Form to include all language required under §709.30(1)?(6), ensuring that clients are fully informed of their rights, including the right to appeal a decision limiting access to their records to the director. The updated form was implemented immediately and uploaded into the electronic health record system for consistent use. The old form is no longer accessible. The Clinical Supervisor will verify that the correct form is being used during weekly chart reviews and will conduct monthly random chart audits to ensure continued compliance. The facility will be in full compliance by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not contain that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 13, 2024 annual licensing inspection.
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Plan of Correction
Hope's Destiny has revised its Client Rights Form to include all language required under §709.30(1)?(6), ensuring that clients are fully informed of their rights, including the right to request correction of inaccurate, irrelevant, outdated, or incomplete information in their records. The revised form was implemented immediately and uploaded into the electronic health record system for consistent use. The old form is no longer accessible. The Clinical Supervisor will verify that the correct form is being used during weekly chart reviews and conduct monthly random chart audits to ensure continued compliance. The facility will be in full compliance by November 30, 2025, with continued oversight by the Chief Operating Officer. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not contain that they have the right to submit rebuttal data or memoranda to their own records.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 13, 2024 annual licensing inspection.
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Plan of Correction
Hope's Destiny has revised its Client Rights Form to include all required language under §709.30(1)?(6), ensuring that clients are fully informed of their rights, including the right to submit rebuttal data or memoranda to their own records. The updated form was implemented immediately and uploaded into the electronic health record system for consistent use. The old form is no longer accessible. The Clinical Supervisor will verify the correct form is being used during weekly chart reviews and will conduct monthly random chart audits to ensure continued compliance. The facility will be in full compliance by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based upon a review of outpatient client records, the facility failed to document medical histories in four out of seven records reviewed.Client #2 was admitted on April 22, 2025 and discharged on July 1, 2025Client #4 was admitted on April 15, 2025 and discharged on June 23, 2025.Client #6 was admitted on May 19, 2025 and discharged on September 5, 2025.Client #7 was admitted on June 2, 2025 and discharged on August 16, 2025.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny will provide training to all clinical staff on November 18, 2025, reinforcing that a complete medical history must be obtained and documented at the time of intake in accordance with §709.91(b)(3)(i). The facility updated its intake assessment form to clearly include a dedicated section for "Medical History," ensuring consistent completion by the evaluating clinician. The Clinical Supervisor will conduct monthly random chart audits to ensure ongoing compliance. The facility will be in full compliance with this standard by November 30, 2025, with continued oversight by the Chief Operating Officer. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based upon a review of outpatient client records, the facility failed to document drug or alcohol histories in four out of seven records reviewed.Client #2 was admitted on April 22, 2025 and discharged on July 1, 2025Client #4 was admitted on April 15, 2025 and discharged on June 23, 2025.Client #6 was admitted on May 19, 2025 and discharged on September 5, 2025.Client #7 was admitted on June 2, 2025 and discharged on August 16, 2025.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny will provide training to all clinical staff on November 18, 2025, reinforcing that a complete drug and/or alcohol history must be obtained and documented at the time of intake in accordance with §709.91(b)(3)(ii). The Clinical Supervisor will verify completion of the drug/alcohol history during monthly random chart audits to monitor ongoing compliance. The facility will be in full compliance with this standard by November 30, 2025, with continued oversight by the Chief Operating Officer. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of outpatient client records, the facility failed to document personal histories in four out of seven records reviewed.Client #2 was admitted on April 22, 2025 and discharged on July 1, 2025Client #4 was admitted on April 15, 2025 and discharged on June 23, 2025.Client #6 was admitted on May 19, 2025 and discharged on September 5, 2025.Client #7 was admitted on June 2, 2025 and discharged on August 16, 2025.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny will provide training to all clinical staff on November 18, 2025, reinforcing that a complete personal history must be obtained and documented at the time of intake in accordance with §709.91(b)(3)(iii). The intake assessment form was updated to clearly include a dedicated section for "Personal History," ensuring that clinicians consistently capture relevant background information during the intake process. The Clinical Supervisor will verify completion of the personal history during monthly random chart audits to ensure ongoing compliance. The facility will be in full compliance with this standard by November 30, 2025, with continued oversight by the Chief Operating Officer. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of outpatient client records, the facility failed to document psychosocial evaluations in four out of seven records reviewed. The facility's policy and procedures manual states the evaluation must be completed within three days of admission. No evaluation was documented in the records.Client #2 was admitted on April 22, 2025 and discharged on July 1, 2025Client #4 was admitted on April 15, 2025 and discharged on June 23, 2025.Client #5 was admitted on January 31, 2025 and discharged on June 18, 2025Client #6 was admitted on May 19, 2025 and discharged on September 5, 2025.Client #7 was admitted on June 2, 2025 and discharged on August 16, 2025.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny will provide targeted training to all clinical staff on November 18, 2025, reinforcing that a complete psychosocial evaluation must be documented within three days of admission in accordance with §709.91(b)(6) and the facility's policy and procedures manual. The psychosocial evaluation template within the electronic health record will be reviewed with clinicians to ensure they understand where and how to complete it immediately following intake. The Clinical Supervisor will verify timely completion of psychosocial evaluations during monthly random chart audits to ensure continued compliance. The facility will be in full compliance with this standard by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of outpatient client records, the facility failed to document an individual treatment plan within the timeframe outlined in the facility's policy and procedures manual in three out of seven records reviewed. The manual states the plan must be completed within 30 days of admission.Client #2 was admitted on April 22, 2025 and discharged on July 1, 2025. A comprehensive treatment plan was due on May 22, 2025; however, none was completed.Client #3 was admitted on April 11, 2025 and discharged on June 25, 2025. A comprehensive treatment plan was due on May 11, 2025; however, it was completed on June 4, 2025.Client #7 was admitted on June 2, 2025 and discharged on August 16, 2025. A comprehensive treatment plan was due on July 2, 2025; however, it was not completed until July 3, 2025.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 13, 2024 annual licensing inspection.
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Plan of Correction
Hope's Destiny is implementing a comprehensive clinical training initiative to ensure full compliance with §709.92(a) regarding the timely completion of comprehensive treatment and rehabilitation plans. A detailed training, covering regulatory requirements, workflow expectations, and best-practice examples of a complete treatment plan, will be provided to all clinical staff. In addition, the facility is creating a Treatment Plan "Cheat Sheet" that outlines mandatory elements, required timelines, and examples of appropriate goals and interventions. This resource will be distributed to all clinicians and uploaded into the company's shared drive for ongoing reference. The Clinical Supervisor will ensure that all current and new staff receive this training and will verify timely treatment plan completion. Monthly random chart audits will also be conducted to ensure continued compliance with the 30-day requirement. Staff will receive initial training on November 18, 2025, and the facility will be in full compliance with this standard by November 30, 2025, with continued oversight by the Chief Operating Officer. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of outpatient client records, the facility failed to document short and long-term goals on the individual treatment plans in two out of six applicable records reviewed.Client #3 was admitted on April 11, 2025 and discharged on June 25, 2025.Client #6 was admitted on May 19, 2025 and discharged on September 5, 2025.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny is implementing a comprehensive clinical training initiative to ensure full compliance with §709.92(a)(1) regarding the development and documentation of short- and long-term goals within each individual treatment and rehabilitation plan. As part of this initiative, clinical staff will receive detailed training on regulatory expectations, how to collaboratively formulate measurable goals with clients, and how to translate these goals into clear, actionable treatment objectives. The facility is also developing a Treatment Plan "Cheat Sheet" that outlines mandatory goal requirements, examples of compliant goal language, and guidance on aligning goals with client needs and level of care. This resource will be distributed to all clinicians and uploaded into the shared drive for ongoing reference. The Clinical Supervisor will ensure that all current and new staff receive this training and will verify that goals are documented appropriately. Monthly random chart audits will be conducted to ensure continued compliance. Staff will receive initial training on November 18, 2025, and the facility will be in full compliance by November 30, 2025, with continued oversight by the Chief Operating Officer. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document support services on the individual treatment plans in two out of six applicable records reviewed.Client #5 was admitted onJanuary 31, 2025 and discharged on June 18, 2025.Client #6 was admitted on May 19, 2025 and discharged on September 5, 2025.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny is implementing a comprehensive clinical training initiative to ensure full compliance with §709.92(a)(3), which requires documentation of proposed support services on treatment and rehabilitation plans. Clinical staff will receive training on identifying appropriate support services?including medical providers, community resources, recovery supports, and internal program services?and how to document them clearly and consistently in the treatment plan. The Treatment Plan "Cheat Sheet" being developed will include examples of acceptable support services, regulatory requirements, and guidance on linking support services to client needs and treatment goals. This resource will be provided to all clinicians and uploaded into the shared drive for ongoing reference. The Clinical Supervisor will confirm that support services are properly documented during monthly random chart audits to ensure continued compliance. Staff will receive initial training on November 18, 2025, and the facility will be in full compliance by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
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 the review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four applicable records reviewed.Client #5 was admitted on January 31, 2025 and discharged on June 18, 2025. A comprehensive treatment plan was completed on February 14, 2025 and an update was due no later than April 14, 2025; however, it was completed on April 29, 2025.Client #6 was admitted on May 19, 2025 and discharged on September 5, 2025. A comprehensive treatment plan was completed on June 11, 2025 and an update was due no later than August 11, 2025; however, none was completed. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hope's Destiny is implementing a comprehensive clinical training initiative to ensure full compliance with §709.92(b) regarding timely 60-day treatment plan updates. Clinical staff will receive targeted training on regulatory deadlines, how to track update due dates, how to reassess client progress, and how to produce compliant treatment plan updates within the required timeframe. The Treatment Plan "Cheat Sheet" will include specific guidance on deadlines, workflow reminders, and examples of compliant update language. This tool will be provided to all clinicians and uploaded into the shared drive for ongoing reference. The Clinical Supervisor will monitor timely completion of 60-day updates during monthly random chart audits to ensure ongoing compliance. Staff will receive initial training on November 18, 2025, and the facility will be in full compliance with this standard by November 30, 2025, with continued oversight by the Chief Operating Officer. |
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 outpatient client records, the facility failed to document case consultations according to the facility's policy and procedures manual. The manual states case consultations shall be completed upon admission. There were no case consultations documented in seven out of the seven records reviewed.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 13, 2024 annual licensing inspection.
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Plan of Correction
Hope's Destiny will provide training to all clinical staff on November 18, 2025, reinforcing the requirement outlined in §709.93(a)(8) and in the facility's policy and procedures manual that case consultations must be completed upon admission and documented in the client record. The Clinical Supervisor will review the case consultation form with staff and clarify the process for completing and uploading the consultation note immediately following intake. The Clinical Supervisor will verify completion of case consultation notes during monthly random chart audits to ensure continued compliance. The facility will be in full compliance with this standard by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of outpatient client records, the facility failed to document follow-up information according to the facility's policy and procedures manual. The manual states follow-up shall be completed within 30 days of discharge. There was no follow-up information documented in five out of seven records reviewed.Client #1 was admitted on April 4, 2025 and discharged on August 1, 2025.Client #2 was admitted on April 22, 2025 and discharged on July 1, 2025.Client #3 was admitted on April 11, 2025 and discharged on June 25, 2025.Client #5 was admitted on January 31, 2025 and discharged on June 18, 2025.Client #7 was admitted on June 2, 2025 and discharged on August 16, 2025. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 13, 2024 annual licensing inspection.
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Plan of Correction
Hope's Destiny will provide training to all clinical staff on November 18, 2025, reaffirming the requirement under §709.93(a)(11) and the facility's policy and procedures manual that follow-up contact must be completed and documented within 30 days of client discharge. Clinicians were retrained on how to correctly track upcoming 30-day follow-ups using their electronic calendars, including entering the discharge date, setting automated reminders, and documenting each follow-up attempt and outcome in the electronic health record. The facility is also updating its internal workflow guidance to outline each step of the follow-up process, including timelines, documentation requirements, and the appropriate location in the chart for recording follow-up information. The Clinical Supervisor will verify the presence and completion of follow-up documentation during monthly random chart audits to ensure continued compliance. The facility will be in full compliance with this standard by November 30, 2025, with ongoing oversight by the Chief Operating Officer. |