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 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 release of information forms in three of seven client records reviewed.
Client #1 was admitted on July 31, 2025 and was discharged on October 8, 2025. There was a release of information form to a funding source signed and dated by the client on July 30, 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.
Client #4 was admitted on July 2, 2025 and was discharged on January 29, 2026. There were release of information forms to a funding source and an emergency contact signed and dated by the client on July 1, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be made included on both of the release forms.
Client #6 was admitted on July 7, 2025 and was active at the time of the inspection. There was a release of information form to an emergency contact signed and dated by the client on February 2, 2026; 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 a consent to release information form in one of seven client records reviewed.
Client #1 was admitted on July 31, 2025 and was discharged on October 8, 2025. There was a release of information form to an emergency contact signed and dated by the client on July 30, 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 #1 was admitted on July 31, 2025 and was discharged on October 8, 2025. There was a release of information form to an emergency contact signed and dated by the client on July 30, 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.
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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 to release information form was offered to the client in four of seven client records reviewed.
Client #1 was admitted on July 31, 2025 and was discharged on October 8, 2025. There were release of information forms to a funding source and an emergency contact signed and dated by the client on July 30, 2025; however, there was no documentation indicating a copy of either consent form was offered to the client.
Client #2 was admitted on August 25, 2025 and was discharged on October 17, 2025. There was a release of information form to a funding source signed and dated by the client on September 26, 2025; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client #4 was admitted on July 2, 2025 and was discharged on January 29, 2026. There were release of information forms to a funding source and an emergency contact signed and dated by the client on July 1, 2025; however, there was no documentation indicating a copy of either consent form was offered to the client.
Client #6 was admitted on July 7, 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 February 2, 2026; however, there was no documentation indicating a copy of 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 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 on that date forward. |
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 two of four applicable client records reviewed.
Client #4 was admitted on July 2, 2025 and was discharged on January 29, 2026. The individual treatment and rehabilitation plan was completed on August 8, 2025, and the first update was due no later than October 8, 2025; however, the update was completed on October 26, 2025.
Client #6 was admitted on July 7, 2025 and was active at the time of the inspection. A treatment plan update was completed on November 10, 2025, and the next update was due no later than January 10, 2026; however, the update was not 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 met with the Clinical leadership team on 3/16/2026 to determine a plan for ongoing compliance with this regulation.
The Clinical Site Supervisor has met with the clinicians at this site to review the citation and reinforce the policy and requirement to complete treatment plan updates every 60 days from the initial treatment plan. Clarification has been provided to the clinicians regarding the when the "clock starts" for documentation and when the updates are required. Active client charts were reviewed for compliance and any treatment plan updates were completed, when necessary. Clinicians were also stressed the importance of this citation, as this has been a repeat citation over the years. Each clinician at this location has been scheduled for additional training on paperwork and deadlines.
The Director of Compliance will complete additional chart audits over the next 90 days to ensure that clinicians are completing treatment plan updates within the required 60 days. If any trends are identified, clinicians will be placed on a Performance Improvement Plan & will be provided with additional support to maintain compliance with their documentation.
Newer clinicians will be monitored closely to ensure they understand the requirements. Ongoing chart audits will continue to be completed in addition to the extra audits for this specific item which are to be conducted by the Director of Compliance and the Clinical Supervisor.
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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 complete treatment plan updates within 60 days was submitted and approved by the Department for the March 28, 2024 and January 17, 2025 annual licensing inspections. Not completing treatment plan updates within 60 days was again found to be a deficiency in the February 20, 2026 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction for the repeat citation has been adjusted this year in an attempt to tackle this ongoing issue of missing treatment plan updates. Additional chart audits for this specific site will be conducted and Performance Improvement Plans will be utilized, if necessary, to ensure this deficiency is resolved and clinicians are held accountable for any failures to have treatment plans completed and updated within the appropriate time frames.
Additionally, ETHOS is in the process of selecting an individual to fill a new position (additional Clinical Leadership) to assist in supporting clinicians with documentation and chart auditing. The Clinical Director will work closely with the Director of Compliance to improve the auditing process and keeping a closer eye on chart compliance. Additional workshops will be developed as well for those clinicians who struggle to meet the documentation requirements.
This will be an ongoing effort throughout the entire year to ensure the citation is not repeated at the next audit. |