INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
A fire extinguisher was found in the hallway of the facility that was labeled as being inspected in April of 2025. The fire extinguisher was due to be re-inspected no later than April of 2026. However, no further inspections were documented for the fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations spoke with the building management, who has confirmed that the fire extinguishers have been inspected as of 8/10/2026. ETHOS has discussed with the building management the need to have the fire extinguishers serviced annually. The building has confirmed that it is their reponsibility to do so and will maintain this responsibility moving forward. ETHOS staff will ensure that this is completed as well by checking the fire extinguishers tags ourselves. |
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 that treatment and rehabilitation plans are reviewed and updated at least every 60 days in two of two applicable records.
Client #1 was admitted to the outpatient level of care on March 10, 2026 and was active at the time of review. Client #1 had a treatment plan completed on March 31, 2026. The next treatment plan update was due to be completed to later than May 30, 2026, however it was not completed until June 1, 2026.
Client #2 was admitted to the outpatient level of care on April 28, 2026 and was active at the time of review. Client #2 had a treatment plan completed on May 18, 2026. The next treatment plan update was due to be completed no later than July 17, 2026, however it was not completed until July 22, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Site Director will immediately begin individualized training with the pertinent clinicians on the completion and documentation of 60-day treatment plan updates. The pertinent clinicians have been met with and reviewed the timeline specifics of documentation (ex: when the "clock starts" with admission and when the updates should be completed, as well as informing the clinicians that the updates do not require signature which is the component that most led to this citation).
The Director of Compliance will complete thorough chart audits for all documentation components on an ongoing basis to ensure continuous compliance. Any identified trends in non-compliance with treatment plan updates will be reported to the Clinical Site Director to ensure additional training is completed. |
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 ensure there is a complete client record which includes follow-up information in one of one applicable record.
Facility policy and procedure states that follow-up information is to be acquired within one week of discharge.
Client #5 was admitted to the outpatient level of care on May 12, 2026 and discharged June 16, 2026. The client record did not contain any follow-up information at the time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Site Director will immediately begin individualized training with the pertinent clinicians on the completion and documentation (via a Follow-Up Note) of follow-up attempts for all discharged clients in a timely manner.
The Director of Compliance will complete thorough chart audits for all documentation components on an ongoing basis to ensure continuous compliance. The Director of Compliance will ensure that the charts of discharged clients are included in the monthly completion of audits to ensure that follow-up attempts are completed and documented within 30 days of discharge. Any identified trends in non-compliance with follow-up completion will be reported to the Clinical Site Director to ensure additional training is completed.
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