INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 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(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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed the mandatory 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of one applicable personnel record reviewed.
Employee #5 was hired as a counselor on November 1, 2024. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than November 1, 2025. There was no documentation in the record indicating the TB/STD training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance conducted an audit of all HR records to determine who was still in need of the TB/STD training. All identified employees (including employee #5) have been contacted and provided with the DDAP TMS website to sign up for any available TB/STD trainings. Each employee was reminded that this is a requirement not an option.
Due to limited options and availability for virtual options provided by DDAP, it appears that the soonest the trainings can be completed will be in June of 2026. This specific training has been challenging for many to complete due to limited availability.
To ensure this citation is avoided in the future, the Director of Operations and Director of Compliance will audit all new hire HR files and notify them to complete this training as soon as possible, along with the HIV training which is already part of the onboarding process. |
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 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 period.
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 Hours spreadsheet closely, especially for the Project 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. |
709.28 (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 November 14, 2025 and was discharged on January 2, 2026. 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 24, 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) is completed. 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 audit process 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 three of eight client records reviewed.
Client #3 was admitted on October 6, 2025 and was active at the time of the inspection. There were release of information forms to a funding source and an emergency contact signed and dated by the client on October 7, 2025; however, there was no documentation indicating either consent form was offered to the client.
Client #4 was admitted on August 26, 2025 and was active at the time of the inspection. There were release of information forms to a funding source and an emergency contact signed and dated by the client on September 4, 2025; however, there was no documentation indicating either consent form was offered to the client.
Client #6 was admitted on July 3, 2025 and was discharged on October 7, 2025. There were release of information forms to a funding source and an emergency contact signed and dated by the client on July 2, 2025; however, there was no documentation indicating 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 received 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 3/6/2026 and is 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 documented and developed with the client in five of eight client records reviewed.
Client #1 was admitted on January 2, 2026 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on January 11, 2026; however, there was no documentation in the record indicating the plan was developed with the client.
Client #3 was admitted on October 6, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on October 16, 2025; however, there was no documentation in the record indicating the plan was developed with the client.
Client #4 was admitted on August 26, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 11, 2025; however, there was no documentation in the record indicating the plan was developed with the client.
Client #7 was admitted on November 14, 2025 and was discharged on January 2, 2026. The individual treatment and rehabilitation plan was signed and dated by facility staff on November 27, 2025; however, there was no documentation in the record indicating the plan was developed with the client.
Client #8 was admitted on November 6, 2025 and was discharged on December 22, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on November 25, 2025; however, there was no documentation in the record indicating the plan was developed with the client.
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 decided that clinicians will now be required to either obtain signature from the client on the treatment plan, or enter a note verifying that the treatment plan has been developed with the client. The date that this note is entered must align with the date in which the treatment plan was completed/signed. Clinicians can chose which action they take to confirm that the treatment plan was reviewed with the client but it must be one of the two actions mentioned above. This is to be effective immediately. |
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 the documentation of follow-up information, in three of four applicable client records reviewed.
Client #5 was admitted on July 10, 2025 and was discharged on October 21, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client #6 was admitted on July 3, 2025 and was discharged on October 7, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client #7 was admitted on November 14, 2025 and was discharged on January 2, 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 24, 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 clients. 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. |