INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 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 a minimum of 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 two applicable personnel records reviewed.
Employee #5 was hired as a counselor on September 6, 2022. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than September 6, 2023. At the time of the inspection, there was no documentation provided indicating the employee completed either training.
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 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
he 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.
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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 two of eight client records reviewed.
Client #2 was admitted on June 25, 2025 and was discharged on July 7, 2025. There was a release of information form to a funding source signed and dated by the client on June 24, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be made documented on the release form.
Client #4 was admitted on August 21, 2025 and was discharged on September 22, 2025. There was a blank release of information form signed and dated by the client on August 21, 2025; however, there was no name of the person, agency or organization to whom the disclosure was to be mad documented 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.
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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 eight client records reviewed.
Client #4 was admitted on August 21, 2025 and was discharged on September 22, 2025. There was a blank release of information form signed and dated by the client on August 21, 2025; however, there was no specific information to be disclosed documented 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 (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 eight client records reviewed.
Client #4 was admitted on August 21, 2025 and was discharged on September 22, 2025. There was a blank release of information form signed and dated by the client on August 21, 2025; however, there was no purpose of the disclosure documented 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 copies of client consent to release information forms were offered to the client in four of eight client records reviewed.
Client #1 was admitted on July 21, 2025 and was discharged on September 15, 2025. There was a release of information to a funding source signed and dated by the client on July 20, 2025; however, there was no documentation in the record indicating a copy of the consent form was offered to the client.
Client #4 was admitted on August 21, 2025 and was discharged on September 22, 2025. There were release of information forms to a funding source, an emergency contact, and a blank form signed and dated by the client on August 21, 2025; however, there was no documentation in the record indicating a copy of any of the consent forms were offered to the client.
Client #7 was admitted on September 29, 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 25, 2025; however, there was no documentation in the record indicating a copy of either consent form was offered to the client.
Client #8 was admitted on October 13, 2025 and was active at the time of the inspection. There were release of information forms to a funding source and an emergency contact that were signed and dated by the client on October 17, 2025; however, there was no documentation in the record 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(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 individual treatment and rehabilitation plans were developed with the client in four of eight client records reviewed.
Client #2 was admitted on June 25, 2025 and was discharged on July 7, 2025. The individual treatment and rehabilitation plan was signed and dated by facility staff on July 1, 2025; however, there was no documentation indicating the plan was developed with the client.
Client #4 was admitted on August 21, 2025 and was discharged on September 22, 2025. There was no individual treatment and rehabilitation plan documented in the record prior to the client being discharged.
Client #6 was admitted on September 8, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on September 10, 2025; however, there was no documentation indicating the plan was developed with the client.
Client #8 was admitted on October 13, 2025 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on October 20, 2025; however, there was no documentation 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 the 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. |
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 documentation of follow-up information per facility policy, in four of four applicable client records reviewed.
The facility policy and procedure manual indicated that follow-up information will be completed within 7 days of discharge.
Client #1 was admitted on July 21, 2025 and was discharged on September 15, 2025. The follow-up information was due to be completed no later than September 22, 2025; however, the information was documented in the record on January 8, 2026.
Client #2 was admitted on June 25, 2025 and was discharged on July 7, 2025. The follow-up information was due to be completed no later than July 14, 2025; however, the information was documented in the record on January 8, 2026.
Client #3 was admitted on July 22, 2025 and was discharged on October 3, 2025. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #4 was admitted on August 21, 2025 and was discharged on September 22, 2025. There was no documentation of follow-up information in the record as of the date of the inspection.
This is a repeat citation from the January 9, 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 client charts to ensure this is being completed. 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. |