INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, American Treatment Network 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan for each employee, with the plan being developed annually, having input from both the employee and their supervisor, and appropriate to that employee's skill level, in ten of ten personnel records reviewed.
Employee # 1 was hired as the project director and facility director on June 23, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 2 was hired as a clinical supervisor on January 18, 2021. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 3 was hired as a counselor on March 28, 2022. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 4 was hired as a counselor on May 13, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 5 was hired as a counselor on April 19, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 6 was hired as a counselor on September 7, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 7 was hired as a counselor on August 24, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 8 was hired as a counselor on September 3, 2024. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 9 was hired as a counselor on July 21, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.
Employee # 10 was hired as a counselor on May 6, 2025. There was no current individual training plan documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has created a new individual training plan and development plan that includes training goals for the year and trainings that employees identify that they would like to take. The training plan will also include a signed upon agreement between employee and supervisor that half of trainings will be completed by June. If this is not completed a corrective action plan will be implemented. This individual training plan will be implemented with each employee by supervisor and facility director annually in January. The next implementation will be January 2026. Supervisor and facility director will meet with each employee in June to monitor their progress on trainings.
Employee 1 will complete the new training plan by January 2026.
Employee 2 will complete the new training plan by January 2026.
Employee 3 will complete the new training plan by January 2026.
Employee 4 will complete the new training plan by January 2026.
Employee 5 will complete the new training plan by January 2026.
Employee 6 will complete new training plan by January 2026.
Employee 7 will complete the new training plan by January 2026.
Employee 8 will complete the new training plan by January 2026.
Employee 9 will complete the new training plan by January 2026.
Employee 10 will complete the new training plan by January 2026.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in five of five applicable personnel records reviewed.
Employee # 4 was hired as a counselor on May 13, 2024 and was due to have the TB/STD training no later than May 13, 2025. The TB/STD training was not completed at the time of the inspection.
Employee # 5 was hired as a counselor on April 19, 2024 and was due to have the TB/STD training no later than April 19, 2025. The TB/STD training was not completed at the time of the inspection.
Employee # 7 was hired as a counselor on August 24, 2024 and was due to have the HIV/AIDS training and the TB/STD training no later than August 24, 2025. Both the HIV/AIDS training and the TB/STD training was not completed at the time of the inspection.
Employee # 8 was hired as a counselor on September 3, 2024 and was due to have the HIV/AIDS training no later than September 3, 2025. The HIV/AIDS training was not completed at the time of the inspection.
Employee # 11 was hired as an office manager on July 17, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than July 17, 2025. Both the HIV/AIDS training and the TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the October 6, 2023 and September 6, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will have each individual employee meet with their supervisor to review training plan goals in July 1, 2026 and will review their hours by 7/1/2026. The facility director and clinical supervisor will review progress on staff's training completions throughout the year to ensure that each employee reaches their goals and completes the necessary hours and mandatory training. The facility director and clinical supervisor will meet monthly to review staff training plans to monitor progress made on completing required DDAP trainings.
Employee 4: Facility director will ensure that employee has signed up and completed the necessary DDAP trainings by 7/1/2026.
Employee 5: Facility director will ensure that employee has signed up and completed the necessary DDAP trainings by 7/1/2026.
Employee: 7: Facility director will ensure that employee has signed up and completed the necessary DDAP trainings by 7/1/2026.
Employee 8: Facility director will ensure that employee has signed up and completed the necessary DDAP trainings by 7/1/2026.
Employee 11: Facility director will ensure that employee has signed up and completed the necessary DDAP trainings by 7/1/2026.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of annual training, during the facility's January 1, 2024 through December 31, 2024 training year, in one of one applicable personnel records reviewed.
Employee # 2 was hired as a clinical supervisor on January 18, 2021. The personnel record documented 2 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will ensure that clinical supervisor's trainings are completed and will check in in June 2026 to make sure that 50 percent of training goals are completed.
Employee 2: Will complete annual training goals and be monitored by the facility director to guarantee that 12 training hours are completed to fulfill the requirement. The facility director will find appropriate training courses that enhance development of skills in role as both therapist and supervisor.
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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 1, 2024 through December 31, 2024 training year, in one of one applicable personnel records reviewed.
Employee # 3 was hired as a counselor on March 28, 2022. The personnel record documented 19.5 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director and supervisor will monitor employees training hours reach 25 a year to fulfill the requirement. Facility director will meet with employees in June 30,2026 to ensure that 50 percent of trainings are complete.
Employee 3: Will complete annual training goals and be monitored by supervisor to guarantee that 25 training hours are completed to fulfill requirement. Will find appropriate training course that enhance development of skills in role as therapist. Supervisor will support therapist in finding and taking time to complete the training hours. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the Full Time Equivalent (FTE) counselor caseloads in an outpatient program did not exceed 35 active clients in six of ten applicable personnel records reviewed.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 1 was hired as the project director and facility director on June 23, 2025 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 15/40= 0.375 (FTE); 20/0.375= 53.3333, which equals to a client/counselor FTE ratio of 53:1.
Employee # 3 was hired as a counselor on March 28, 2022 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 15/40= 0.375 (FTE); 15/0.375= 40, which equals to a client/counselor FTE ratio of 40:1.
Employee # 4 was hired as a counselor on May 13, 2024 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 31/40=0.775 (FTE); 31/0.775= 40, which equals to a client/counselor FTE ratio of 40:1.
Employee # 5 was hired as a counselor on April 19, 2024 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 13/40= 0.325 (FTE); 13/0.325= 40 which equals to a client/counselor FTE ratio of 40:1.
Employee # 6 was hired as a counselor on September 7, 2024 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 31/40=0.775 (FTE); 31/0.775= 40, which equals to a client/counselor FTE ratio of 40:1.
Employee # 7 was hired as a counselor on August 24, 2024 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 13/40= 0.325 (FTE); 13/0.325= 40 which equals to a client/counselor FTE ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor and clinical director will monitor therapist's caseloads 1x a month to ensure that they do not exceed the 35:1 ratio. If a therapist is over the ratio, client will be re-assigned to ensure that therapist stays within the guidelines. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's October 2024 through August 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided indicating unannounced fire drills were conducted during the months of March 2025 and April 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director and supervisor will ensure that unannounced fire drills are completed monthly 100 percent of the time.
Facility director and supervisor will review fire drill log before the end of the month to ensure that an unannounced fire drill was completed and documented appropriately. |
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 the facility's October 2024 through August 2025 fire drill logs, the facility failed to ensure their written fire drill logs included the documentation of the amount of time it took for evacuation, the exit route used, and/or the number of persons in the facility at the time of the drill.
Every monthly fire drill log documented during the reviewed period did not include the exit route used. Additionally, the July 2025 fire drill log did not include the amount of time for evacuation, and the October 2024, and the December 2024 through August 2025 fire drill logs did not include the number of persons in the facility at the time of the drill.
This is a repeat citation from the July 26, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and supervisor will ensure that fire drills are done monthly and appropriate documentation is completed including exit route, amount time for evacuation, and number of people in evacuation.
Supervisor and facility director will monitor documentation monthly to ensure all fire drill paperwork is completed appropriately. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the October 2024 through August 2025 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's posted hours of operation are Monday through Friday from 8:00am to 8:30pm. There were no afternoon or evening fire drills conducted during the reviewed period, as every fire drill documented was conducted between 9:00am and 12:00pm.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director and supervisor will ensure that monthly fire drills are completed at different times and days. The facility director and supervisor will review previous month's fire drill to ensure timing and days are different. Fire drills will be randomly completed between hours of 8:00am and 8:30pm Monday through Friday. |
709.22 (b) (1) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(1) Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report, which is to include, but not be limited to, a statement disclosing the names of officers, directors and principal shareholders.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
Fiscal Management: The project director discussed with the CEO that an annual report needs to be added to the website for the public to view.
The project director and CEO completed a link that directs them to the annual report and will be available by November 30, 2025.
The verbiage is as follows: DDAP regulation: 709.22 (C): American Treatment Network LLC
If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors, and principle share holders, when applicable.
American Treatment Network is owned and governed by Matthew Judge Sullivan founder/CEO and Thomas Connor founder/COO. |
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 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.
The project had a current, approved exception to the regulation requiring an audit if the project's gross income is less than $500,000. A copy of the project's most recent tax return was provided during the inspection, and the returns indicated the project's gross income exceeded $500,000; therefore, the exception is no longer valid, and a financial audit must be completed. There was no financial audit completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director discussed with the CEO that an independent certified public accountant for an annual financial audit needs to be completed annually. The project director will ensure that the CEO will complete the financial audit annually.
The project director communicated with all interest parties that are related to the external financial audit, was informed that the related financial audit will be completed by April 15, 2026. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 6 was admitted to on January 22, 2025 and was discharged on June 17, 2025. There was evidence 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 any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will audit all consents upon intake to ensure that all consents needed are signed by both staff and by client. If it is not obtained, clinical supervisor will instruct the intake worker to contact the client and obtain all missing consents.
Client 6: Assessor, therapist and clinical supervisor will review charts to make sure that all necessary releases are signed including funding sources. Two charts will be audited by facility director and supervisor monthly to ensure compliance with releases. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a release of information form in one of seven client records reviewed.
Client # 4 was admitted on February 10, 2025 and was discharged on July 11, 2025. The release of information form to a pharmacy was signed by the client on February 10, 2025; however, the release form did not include the purpose of the disclosure.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor will audit all consents upon intake to ensure that all consents needed are signed and not left blank by both staff and by client. If it is not obtained, clinical supervisor will instruct the intake worker to contact the client and obtain all missing consents.
Client 4: Assessor, therapist and clinical supervisor will review charts to guarantee that releases are completed correctly. If release is not filled out correctly the release will need to be done over and signed by client. Facility director and supervisor will audit 2 charts monthly to maintain compliance with releases. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to also include the reason for termination, in one of one applicable client record reviewed.
Client # 4 was admitted on February 10, 2025 and was administratively discharged on July 11, 2025. There was no documentation in the record indicating the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor and Facility Director will create a letter that will be sent to each client that is administratively discharged. Supervisor will verify through chart audit that letter was sent to client by assigned clinician.
Client 4: All administrative discharges will be notified in writing starting 11/1/2025 which gives them opportunity to dispute the discharge. Facility Director and supervisor will respond to any disputes of clients discharge. |
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 client records, the facility failed to ensure treatment and rehabilitation plans are reviewed and updated at least every sixty days in two of six applicable client records reviewed.
Client # 2 was admitted on April 2, 2025 and was still active at the time of the inspection. A treatment plan updated was completed on June 6, 2025 and the next update was due no later than August 6, 2025; however, the update was not completed until August 29, 2025.
Client # 3 was admitted on February 17, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 24, 2025 and the first update was due no later than April 24, 2025; however, the update was not completed until April 29, 2025.
This is a repeat citation from the December 1, 2021, October 14, 2022, October 6, 2023, and September 6, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and supervisor will work with staff during supervision to monitor treatment plan updates and ensure treatment plans are within compliance.
Client 2 will have treatment plans completed within regulatory guidelines.
Client 3 will have treatment plans completed within regulatory guidelines. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to review and update treatment and rehabilitation plans at least every sixty days was submitted and approved by the Department for the December 1, 2021, October 14, 2022, October 6, 2023, and September 6, 2024 annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the September 26, 2025 licensing inspection.
A plan of correction for failing to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was submitted and approved by the Department for the October 6, 2023 and September 6, 2024 annual licensing inspections. Failing to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was again found to be a deficiency in the September 26, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will review treatment plans at least 30 days before to ensure the facility is in compliance with the annual licensing inspections to ensure that the deficiency will not continue to happen. The project director will review at least 20% of client charts monthly to ensure that treatment plans are within compliance.
The project director and clinical supervisor will complete randomized audits 1x a month to ensure all previous deficiencies are correct to avoid any further citations.
Once a month during clinical meetings we will review one chart with the entire staff to identify any deficiencies. Facility director and clinical supervisor will continue to utilize audits to monitor charts to ensure they are not presenting with any repeat deficiencies. |