INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Horizons Treatment Center 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 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of February 2025 through February 2026, the facility failed to provide documentation of a fire drill being conducted the month of December 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director identified agency was not in compliance with 705.28 (d)(1) prior to the scheduled site visit on 2/18/26. As a result, a plan was implemented immediately to correct this issue and ensure continued compliance.
- The Facility Director is responsible for conducting unannounced monthly fire drills. On 2/4/26, the Project Director, was identified as the new Facility Director.
- The Project Director is now responsible for conducting all fire drills per regulation(s) and all staff have been advised of this change.
- The Project Director has preselected dates (randomly) throughout the remainder of the year to ensure drills will be completed per regulation.
- The Project Director has set up reminders for each of these dates on calendar (not accessible/visible to staff) to ensure that drills are completed per regulation. The reminder will alert every day until it is marked as completed.
- Project Director has shared these preselected dates with the Office Manager who will set up reminders on their calendar to support the Project Director and/or facilitate the fire drills if necessary to ensure compliance with regulation.
- The Project Director has already demonstrated adherence to this plan by completing unannounced fire drills in both January and February.
- The Project Director advised staff of noncompliance and reviewed the requirements associated with this regulation.
- The Project Director reviewed the agency's procedure for fire drills and communicated expectations related to ongoing compliance.
- The Project Director offered staff the opportunity to discuss any of the changes identified herein, as well as to present any questions or concerns specific to this deficiency. |
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 fire drill log for the months of February 2025 through February 2026, the facility failed to maintain a written fire drill record including the date of the drill, time of the drill, the amount of time it took for evacuation, and the number of persons in the facility at the time of the drill for the months of February 2025 through November 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director identified agency was not in compliance with 705.28 (d)(4) prior to the scheduled site visit on 2/18/26. As a result, a plan was implemented immediately to correct this issue and ensure continued compliance.
- The Facility Director is responsible for conducting unannounced monthly fire drills. On 2/4/26, the Project Director, was identified as the new Facility Director.
- The Project Director is now responsible for conducting all fire drills per regulation(s) and all staff have been advised of this change.
- The Project Director verified existing Fire Drill Log contains the following data, thereby adhering to regulation:
1. DATE OF DRILL
2. TIME OF DRILL
3. TOTAL TIME OF DRILL
4. EXIT UTILIZED
5. # OF PEOPLE IN THE BUILDING (SPECIFYING # OF EMPLOYEES AND # OF PATIENTS)
6. STAFF CONDUCTING DRILL
7. WAS THE SMOKE DETECTOR OPERATIVE?
8. CONSULTAT WITH EXECUTIVE DIRECTOR (ISSUES TO DISCUSS)
9. COMMENTS
- The Project Director has already demonstrated adherence to this plan by completing unannounced fire drills in both January and February and recording related data on Fire Drill Log 2026.
- The Project Director will share this information with the Office Manager, and they will review the Fire Drill Log (for the current year) to ensure all data is being recorded each month to reflect compliance with this regulation.
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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 applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in accordance with the facility ' s policy in three of seven applicable records. The facility ' s policy states the comprehensive treatment plan is to be completed within twenty-one days of admission.
Client #1 was admitted on August 22, 2025 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan was due to be completed no later than September 12, 2025; however, this was not completed until September 24, 2025.
Client #6 was admitted on April 15, 2025 and was discharged on January 29, 2026.
The comprehensive treatment and rehabilitation plan was due to be completed no later than May 6, 2025; however, this was not completed until May 9, 2025.
Client #7 was admitted on August 27, 2025 and was discharged on January 13, 2026.
The comprehensive treatment and rehabilitation plan was due to be completed no later than September 17, 2025; however, this was not completed until September 29, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency's current policy states the master treatment plan must be developed within 21 days of admission and include the patient's input and approval to finalize (implement plan of care). It was determined that 21-days was too restrictive and to ensure compliance with 709.92 (a) going forward, there needed to be an adjustment. The updated policy, effective March 30, 2026, now reflects that the master treatment plan must be completed before the third outpatient appointment.
- The Project Director reviewed the current procedure for completing treatment plans with staff, including time frames and how to ensure compliance with regulation until updated policy is in effect.
- The Project Director will review the updated policy with staff and explain the rationale for changing time frame re: master treatment plan development by March 31, 2026.
- The Project Director offered staff the opportunity to discuss this change, as well as to present any questions or concerns specific to this deficiency.
- The Project Director will randomly audit (3-5) patient records per month to ensure compliance with this regulation. |