INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 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 citation. 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 moving forward, 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 and submitted by December 1st to allow the Director of Compliance additional time to complete a final review & audit of training hours before year-end. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on review of the facility's January 2025 through December 2025 fire drill logs, the facility failed to set off the fire alarm or a smoke detector during each fire drill.
At the time of the inspection, every fire drill conducted during the reviewed period did not include documentation indicating whether a fire alarm or a smoke detector was set off.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ETHOS has revised its Fire Drill and Fire Safety Policy to explicitly require that all fire drills include activation of the fire alarm or smoke detector, unless activation is prohibited by the local fire authority (in which case written documentation and an alternative approved method will be used).
All staff in this office were notified re-educated on proper fire drill procedures, including:
Activation of the fire alarm system during drills
Required staff and resident response
Documentation requirements for fire drills
Fire drill documentation forms have been updated to include a required checkbox and narrative field confirming alarm activation during each drill.
The Director of Compliance will review fire drill documentation monthly for the next 12 months to ensure:
Fire drills are conducted as scheduled
Fire alarms or smoke detectors are activated
Documentation is complete and accurate
Any identified issues will be addressed immediately with corrective action and retraining as needed. |