INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 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 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 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. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.
Client #8 was admitted on October 28, 2025 and was active at the time of the inspection. There was a blank release of information form signed and dated by the client on October 28, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance and the Director of Operations met to discuss this citation and a plan to move forward to avoid this issue. Effective immediately, the intake department will no longer send out blank releases with the intake packet. This will avoid the issue of blank ROI being signed and left in the chart. Additionally, blank insurance ROI's were identified as an issue within the new EMR early on in the transition to the new software. Within the software, there was a glitch that was not pulling the insurance information from the demographics page to the release form. This has since been corrected with the EMR and has not been an issue since resolved.
Lastly, the Director of Compliance has been given permissions within the system to revoke/delete any blank release forms from client charts for any that were completed prior to the changes in the system and the ETHOS workflow. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in two of seven client records reviewed.
Client #2 was admitted on September 30, 2025 and was discharged on January 3, 2026. There was a release of information form to an emergency contact signed and dated by the client on September 29, 2025; however, there was no specific information to be disclosed included on the release form.
Client #8 was admitted on October 28, 2025 and was active at the time of the inspection. There was a blank release of information form signed and dated by the client on October 28, 2025; however, there was no specific information to be disclosed included on the release form.
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 the plan to correct this deficiency. It has been decided that moving forward, all intake documents will now be reviewed one by one during chart audits, to ensure all required signatures are captured and that all releases are completed in their entirety. This item has been added to the internal Chart Audit checklist to ensure ongoing auditing for this specifically. Additionally, clinicians have been notified that they are to also check all release forms prior to the start of treatment, to ensure all are completed correctly and entirely. In the event anything is missing, a client is not to begin treatment until all documents are completed as required. |
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 include the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client #8 was admitted on October 28, 2025 and was active at the time of the inspection. There was a blank release of information form signed and dated by the client on October 28, 2025; however, there was no purpose of the disclosure included on the release form.
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 the plan to correct this deficiency. It has been decided that moving forward, all intake documents will now be reviewed one by one during chart audits, to ensure all required signatures are captured and that all releases are completed in their entirety. This item has been added to the internal Chart Audit checklist to ensure ongoing auditing for this specifically. Additionally, clinicians have been notified that they are to also check all release forms prior to the start of treatment, to ensure all are completed correctly and entirely. In the event anything is missing, a client is not to begin treatment until all documents are completed as required. |
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 seven of eight client records reviewed.
Client #2 was admitted on September 30, 2025 and was discharged on January 3, 2026. There was a release of information form to probation and parole signed and dated by the client on September 29, 2025; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client #3 was admitted on September 2, 2025 and was discharged on December 16, 2025. There were release of information forms to a funding source and an emergency contact signed and dated by the client on August 22, 2025; however, there was no documentation indicating a copy of both consent forms were offered to the client.
Client #4 was admitted on September 12, 2025 and was discharged on December 30, 2025. There was a release of information form to a case manager signed and dated by the client on September 16, 2025; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client #5 was admitted on July 7, 2025 and was active at the time of the inspection. There was a release of information form to an attorney signed and dated by the client on October 28, 2025; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client #6 was admitted on August 26, 2025 and was active at the time of the inspection. There was a release of information form to an attorney signed and dated by the client on December 30, 2025; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client #7 was admitted on October 28, 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 24, 2025; however, there was no documentation indicating a copy of both consent forms were offered to the client. Additionally, there was a release of information form to an emergency contact signed and dated by the client on February 3, 2026; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client #8 was admitted on October 28, 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 28, 2025; however, there was no documentation indicating a copy of both consent forms were offered to the client. Additionally, there was a blank release of information form signed and dated by the client on October 28, 2025; however, there was no documentation indicating a copy of the 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 3/6/2026 and was effective for all forms completed from 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 the individual treatment and rehabilitation plan was developed with the client in seven of eight client records reviewed.
Client #1 was admitted on July 24, 2025 and was discharged on October 3, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on August 17, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #3 was admitted on September 2, 2025 and was discharged on December 16, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 14, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #4 was admitted on September 12, 2025 and was discharged on December 30, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 26, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #5 was admitted on July 7, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on July 24, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #6 was admitted on August 26, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 9, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #7 was admitted on October 28, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on November 8, 2025; however, there was no written documentation indicating the plan was developed with the client.
Client #8 was admitted on October 28, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on November 7, 2025; however, there was no written documentation indicating the plan was developed with the client.
This is a repeat citation from the January 10, 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 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. |