INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 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:
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Plan of Correction
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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.
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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.
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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. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's January 2025 through December 2025 training year in one of two applicable personnel records reviewed.
Employee #3 was hired as a counselor on June 29, 2023. The personnel record documented 18.5 hours of annual training during the reviewed period.
This is a repeat citation from the January 23, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance spoke with the counselor (Employee #3) to remind them of the 25-hour training requirement. The Director of Compliance will not only track the training hours more closely by keeping the Training Log spreadsheet updated, but the spreadsheet will now be sent out on a monthly basis vs. a quarterly basis. Additionally, the cutoff date to submit training hours will now be December 1st, to allow for enough time for the Director of Compliance to do a thorough audit of training hours. This will also allow the counselors enough time to be notified of insufficient hours & complete additional trainings before end of year. |
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 written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of eight client records reviewed.
Client #7 was admitted on October 23, 2025 and was discharged on December 5, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the January 23, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance, Clinical Leadership and the Director of Operations met to discuss this citation and ongoing issue. It was decided that it is now policy of ETHOS that clinicians are not permitted to admit clients to treatment until all intake paperwork (which includes all consent forms to release information). Clinicians have been made aware of this new requirement.
Additionally, the internal chart audit checklist has been updated to reflect this item as an area that needs to be checked when conducting chart audits. Release forms were always apart of the chart audit but now it is noted to check the dates of completion and when the client began treatment. Chart audits are conducted on a regular/ongoing basis so this item has been added effective immediately. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent form was offered to the client in two of eight client records reviewed.
Client #4 was admitted on September 15, 2025 and was discharged on January 16, 2026. There were release of information forms to a funding source and an emergency contact signed and dated by the client on September 11, 2025; however, there was no documentation indicating a copy of either consent form was offered to the client.
Client #8 was admitted on September 23, 2025 and was active at the time of the inspection. There were release of information forms to a funding source and an emergency contact that were signed and dated by the client on September 27, 2025; however, there was no documentation indicating a copy of either consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations has revised all Release of Information forms to include the following statement: "My signature verifies that I was offered a copy of this release."
This revision was completed on 3/6/3026 and was effective for all forms completed on that date forward. |
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 client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client in three of seven applicable client records reviewed.
Client #2 was admitted on September 9, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 16, 2025; however, there was no documentation in the record indicating the plan was developed with the client.
Client #4 was admitted on September 19, 2025 and was discharged on January 16, 2026. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 16, 2025; however, there was no documentation in the record indicating the plan was developed with the client.
Client #8 was admitted on September 23, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on October 14, 2025; however, there was no documentation in the record indicating the plan was developed with the client.
This is a repeat citation from the January 23, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance and the Clinical Leadership team developed a workflow that requires the clinicians to enter documentation via a General Note that states the treatment plan was developed with the client. Clinicians have been notified of this documentation addition and were alerted that this is effective immediately.
To ensure ongoing compliance, this item has been added to the auditing checklist for the Director of Compliance to check during regular and ongoing chart audits. |
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 client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in one of three applicable client records reviewed.
Client #4 was admitted on September 19, 2025 and was discharged on January 16, 2026. There was no documentation of follow-up information in the record as of the time of the inspection.
This is a repeat citation from the January 23, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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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. |