INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 19, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ethos Treatment LLC 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
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel records, the facility failed to ensure the project director and facility director completed at least 12 clock hours of annual training during the facility's January 1, 2025 through December 31, 2025 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the project director and facility director on November 1, 2021. The personnel record documented 1 hour of annual training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Compliance met with the Project/Facility Director to discuss this deficiency. The individual had 8 hours submitted and was unable to obtain certificates for previous training hours completed throughout 2025. To ensure this does not happen again, the Director of Compliance will monitor the Training Hour Spreadsheet more closely, especially for the Program Director, and provide status updates more frequently throughout the year (monthly email updates vs. quarterly email updates). Additionally, it is now required that all training hours are met by December 1st, to allow the Director of Compliance additional time to complete a final review & audit of training hours before year-end.
|
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of four applicable client records reviewed.
Client #2 was admitted on February 13, 2025 and was discharged on January 5, 2026. There was no documentation of follow-up information in the record at the time of the inspection.
Client #3 was admitted on November 13, 2025 and was discharged on January 20, 2026. There was no documentation of follow-up information in the record at the time of the inspection.
This is a repeat citation from the January 16, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Compliance and Clinical Leadership met to discuss this issue. To correct the issue, the team has decided to conduct more chart audits on discharged client charts to ensure this is being completed. Most chart audits are conducted while clients are still in treatment so it will now be required of the Director of Compliance to audit at least 2 random discharged charts for each clinician to ensure this item is included in the charts.
Additionally, ETHOS has revised it's Follow-up Policy to reflect a new timeline of "within 30 days of discharge" rather than "within 7 days of discharge" to allow the clinicians more time to get this item completed.
|