INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 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 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(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 ensure a written individual training plan was developed annually for each employee, with input from both the employee and their supervisor and appropriate to that employee's skill level, in one of five personnel records reviewed.
Employee # 5 was hired as the project director on June 23, 2025. There was no current individual training plan, developed with input from the employee and supervisor, 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 will develop a comprehensive a written individual training plan annually for each employee with input from both the employee and their supervisor addressing the appropriate employee's skill level.
Employee # 5 was hired as the project director on June 23, 2025. By 12/31/2025 the employee #5 will have a current individual training plan developed with input from the employee # 5 and the facility director.
The facility director will monitor to ensure all training plans meet the standards and policies have been included with input from both the employee and their supervisor addressing the appropriate employee's skill level.
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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 two of two applicable personnel records reviewed.
Employee # 2 was hired as a counselor on March 13, 2023 and was due to have the TB/STD training no later than March 13, 2024; however, the TB/STD training was not completed at the time of the inspection.
Employee # 4 was hired as a counselor on July 2, 2024 and was due to have the HIV/AIDS training and the TB/STD training no later than July 2, 2025; however, the HIV/AIDS training was not completed until August 5, 2025 and the TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the September 5, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will provide a list of all training needs of each staff member.
The facility director will identify required training in the overall training plan each year and monitor progress for staff once per month with each staff member.
Employee #4 will complete TB/STD by December 31st, 2025
Employee #2 is no longer an employee. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel, on all shifts, were trained to perform assigned tasks during emergencies in one of one applicable personnel record reviewed.
Employee # 5 was hired as the project director on June 23, 2025. There was no documentation in the personnel record indicating the emergency preparedness training was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project director will review all personnel records to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies and monitor personnel records 100 percent every month.
Employee #5 was hired as the project director on June 23, 2025, and will review and monitor that every employee completes the emergency preparedness training by December 31st, 2025. |
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 September 2024 through September 2025 fire drill logs, the facility failed to ensure their written fire drill logs included documentation of the amount of time it took for evacuation and whether the fire alarm or smoke detector was operative.
At the time of the inspection, the September 2024 fire drill log did not include documentation indicating the amount of time it took for evacuation during the drill. Additionally, the September 2024, July 2025, and September 2025 fire drill logs did not include documentation indicating if the fire alarm or smoke detector was operative at the time of the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will review and monitor the fire drill logs monthly to ensure that the fire drill logs include documentation of the amount of time it took for evacuation and whether the fire alarm or smoke detector is operative.
The facility director will include the amount of time it took for evacuation during the drill and ensure that the fire alarm or smoke detector is operative at the time of each fire drill every month. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's September 2024 through September 2025 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
At the time of the inspection, every fire drill conducted, during the reviewed period, used the front door as the only exit route.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will review the fire drill logs monthly and ensure that the facility is using alternate exit routes during each monthly fire drill.
The facility director will conduct monthly fire drills and use alternate exit routes during each monthly fire drill. |
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 a review of the facility's September 2024 through September 2025 fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill.
At the time of the inspection, the September 2024, July 2025, and September 2025 fire drill logs did not include documentation indicating if a fire alarm or smoke detector was set off during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will monitor the facility's fire drill logs to ensure that the facility sets off the fire alarm or smoke detector alarm 100 percent of the time during the fire drill each month.
The facility director will ensure that the fire drill log documentation indicates if the fire alarm or the smoke detector was set off during the fire drill each month, 100 percent of the time. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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 principal shareholders, when applicable.
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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
The facility will make a public and annual report that will include the statement disclosing the names of officers, directors, and principal shareholders. This statement will be published on the facility website for the public to review.
The project director will ensure that this is updated annually on the facility website.
This will be implemented by 12/31/2025 |
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 completes a financial audit annually.
The project director communicated with all interested parties that are related to the external financial audit and was informed that the financial audit will be resolved on April 15, 2026. |
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 the disclosure is made on consent to release information forms in three of seven client records reviewed.
Client # 2 was admitted on February 20, 2025 and was active at the time of inspection. A release of information form to a government agency was signed by the client on February 20, 2025; however, the release form did not include documentation of the name of the person, agency or organization to whom the disclosure would be made.
Client # 4 was admitted on September 24, 2024 and was discharged on March 5, 2025. The release of information form to a government agency was signed by the client on August 9, 2024; however, the release form did not include documentation of the name of the person, agency or organization to whom the disclosure would be made.
Client # 5 was admitted on December 2, 2024 and was discharged on July 29, 2025. The release of information form to a government agency was signed by the client on January 7, 2025; however, the release form did not include documentation of the name of the person, agency or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that staff document the name of the person, agency, or organization to whom the disclosure is made on consent-to-release information forms by conducting monthly reviews of releases of information.
The facility director will monitor the staff client's documentation by having the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms, and by conducting chart reviews monthly during clinical or individual supervision.
Client #2 will have the release of information updated with the name of the person and, agency to whom the disclosure would be made by 12/31/2025.
Client #4 was discharged on March 5, 2025, and will be unable to update the release of information.
Client # 5 was discharged on March 5, 2025, and will be unable to update the release of information. |
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 developed with the client in three of seven client records reviewed.
Client #3 was admitted on June 5, 2025 and was active at the time of inspection. The individual treatment plan was signed by the clinician on June 6, 2025; however, the client did not sign until July 14, 2025 and there was no other documentation in the record indicating the plan was developed with the client's input.
Client #4 was admitted on September 24, 2024 and was discharged on March 5, 2025. The individual treatment plan was signed by the clinician on October 21, 2024; however, the client did not sign until October 31, 2024 and there was no other documentation in the record indicating the plan was developed with the client's input.
Client #7 was admitted on April 30, 2025 and was discharged on July 25, 2025. The individual treatment plan was signed by the clinician on May 12, 2025; however, the client did not sign until June 18, 2025 and there was no other documentation in the record indicating the plan was developed with the client's input.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director and the facility director will provide training to staff quarterly to ensure that staff are developing individual treatment plans with their clients and providing documentation in a case management note or progress note reflecting the client's input with their individual treatment plans.
The facility director will monitor the client's treatment plans monthly during individual supervision or clinical supervision to ensure documentation reflects the client's input with a progress note or a case management note.
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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 were reviewed and updated at least every sixty days in four of seven client records reviewed.
Client # 3 was admitted on June 5, 2025 and was still active at the time of the inspection. The individual treatment plan was completed on June 6, 2025 and the first update was due no later than August 6, 2025; however, the update was not completed until August 27, 2025.
Client # 4 was admitted on September 24, 2024 and was discharged on March 5, 2025. A treatment plan update was completed on December 23, 2024 and the next update was due no later than February 23, 2025; however, the update was not completed prior to discharge.
Client # 6 was admitted on January 13, 2025 and was discharged on May 29, 2025. A treatment plan update was completed on March 26, 2025 and the next update was due no later than May 26, 2025; however, the update was not completed prior to discharge.
Client # 7 was admitted on April 30, 2025 and was discharged on July 25, 2025. The individual treatment and rehabilitation plan was completed on May 12, 2025 and the first update was due no later than July 12, 2025; however, the update was not completed prior to discharge.
This is a repeat citation from the September 25, 2023 and September 5, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that an updated treatment and rehabilitation plan is reviewed at least every sixty days, with a minimum of 25% of the client's chart reviewed monthly.
The facility director will review treatment and rehabilitation plans by reviewing 50 percent of the client's charges on a monthly basis to ensure that treatment plans are updated at least every 60 days.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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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 an aftercare plan, in one of two applicable client records reviewed.
Client # 7 was admitted on April 30, 2025 and was discharged on July 25, 2025. There was no aftercare plan documented in the record at the time of the inspection.
This is a repeat citation from the September 25, 2023 and September 5, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project Director will monitor at least 25% of discharges every month to ensure documentation of an aftercare plan is documented in the discharge client's charts.
The facility director reached out to client # 7 on 10/24/2025 to complete an aftercare plan. The facility director completed a case management note to reflect the outreach.
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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 and the facility policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable client records reviewed.
The facility policy and procedure manual stated that follow-up information will be completed within 30 days of discharge.
Client # 5 was admitted on December 3, 2024 and was discharged on July 29, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 7 was admitted on April 30, 2025 and was discharged on July 25, 2025. There was no follow-up information documented in the record as of the date of the inspection.
This is a repeat citation from the September 25, 2023 and September 5, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will continue to review the facility policy and procedure manual with the staff monthly to address to address that staff are following up and completing documentation within 30 days of discharge so this will not be a continuous citation at the facility.
The facility director has communicated and implemented to all clinical staff that the facility policy and procedures of discharge will be documented within 30 days of a client's discharge.
The facility director will continue to monitor and documented all discharge outreaches to confirm the plan is being completed monthly.
Client # 5 discharge outreach was completed on 10/24/25 and a case-management note was documented in the client chart.
Client #7discharge outreach was completed on 10/24/25 and a case-management note was documented in the client chart. |
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 September 25, 2023 and September 5, 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 October 1, 2025, licensing inspection.
A plan of correction for failing to document follow-up information after discharge was submitted and approved by the Department for the September 25, 2023 and September 5, 2024 annual licensing inspections. Failing to document follow-up information after discharge was again found to be a deficiency in the October 1, 2025, licensing inspection.
A plan of correction for failing to document an aftercare plan was submitted and approved by the Department for the September 25, 2023 and September 5, 2024 annual licensing inspections. Failing to document an aftercare plan was again found to be a deficiency in the October 1, 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 complies with the annual licensing inspections, to ensure that the deficiency will not continue to happen.
The project director will review at least 25 percent of discharges monthly to ensure that a 30-day discharge follow up is being completed.
The project director will review at least 25 percent of clients' charts monthly to ensure that an aftercare plan has been submitted
The facility director will continue to review discharge charts every month to ensure that treatment plans, discharges, and after-care plans are completed and documented in the client's charts. |