INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 3, 2025 through April 4, 2025 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 Recovery Centers, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months in the position in one of one applicable personnel record reviewed.
Employee #3 was hired as a clinical supervisor on June 11, 2024. There were no documented monthly supervision meetings in the record during the employee's first 6 months in the position.
This is a repeat citation from the May 5, 2023 and April 30, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s). A Supervisory Meeting form has been created and will be implemented for all current applicable staff and any applicable new hires with the Company to track the monthly completion of these meetings. The Company orientation packets and employee training plans have been updated to include a section if this requirement is applicable or not as well. To ensure ongoing compliance meetings will be placed on Company calendar for completion and employee file audits will be completed randomly to check for completion. Citation and Current applicable staff corrective action date is set for November 2025. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor met the educational qualifications for the position in one of four applicable personnel records reviewed.
Employee # 5 was hired as a counselor on January 6, 2025 and was still in the position at the time of the inspection. The employee has a bachelor's degree in public health; however, public health is not a qualifying major for the position.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review citation and regulation(s). The employee associated with this finding will have their training plan updated and reviewed with Executive Director to ensure proper completion moving forward. To ensure ongoing compliance proper review of current and potential employee qualifications will be completed and checked with regulations to ensure they are placed in the correct position. Corrective action date is set for 5/1/2025. |
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 at least 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 within the regulatory time frame in two of four applicable personnel record reviewed.
Employee # 2 was hired as a counselor on October 7, 2022. The HIV/AIDS and TB/STD trainings were due no later than October 7, 2023. There was documentation the HIV/AIDS training was completed late on March 11, 2025. Also, there was documentation of a combination of 4 hours of TB/STD and other health related topics trainings were completed on March 20, 2025 and March 21, 2025; however, none of the TB/STD trainings were Department-approved curriculums.
Employee # 7 was hired as a counselor on June 19, 2023. The HIV/AIDS and TB/STD trainings were due no later than June 19, 2024; however, the HIV/AIDS training was completed late on April 3, 2025 and the TB/STD training was not completed as of the date of the inspection.
This is a repeat citation from the April 30, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s). All current employees will meet to review their current training plans and all needed items including deadline dates. To ensure ongoing compliance the Executive Director and Chief Compliance Officer will schedule reoccurring meetings quarterly to review training plans to ensure they are being completed within regulations timeframes. Outstanding trainings for employees listed in the deficiency are signed up and scheduled to be completed on 5/19/2025. Corrective action date is set for 7/1/2025. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually, during the facility's December 1, 2023 through November 30, 2024 training year, in one of two applicable personnel records reviewed.
Employee # 7 was hired as a counselor on June 19, 2023. There was documentation in the personnel record indicating only 13 hours of training was completed during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s). All current employees will meet to review their current annual training plans and all needed items for annual trainings including deadline dates. To ensure ongoing compliance the Executive Director and Chief Compliance Officer will schedule reoccurring meetings quarterly to review training plans to ensure they are being completed within regulations timeframes. Corrective action date is set for 7/1/2025. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in six of fourteen applicable client records reviewed.
The facility policy and procedure manual stated the individual treatment and rehabilitation plan (master treatment plan) is to be completed "after the completion of the assessment and screening process, and at the time of admission."
Client # 4 was admitted to the partial hospitalization activity on January 23, 2025 and was discharged on February 6, 2025. The individual treatment and rehabilitation plan was due to be completed on January 24, 2025, after the assessment and screening process was completed, however; the plan was completed on January 30, 2025.
Client # 5 was admitted to the partial hospitalization activity on February 13, 2025 and was discharged on February 28, 2025. The individual treatment and rehabilitation plan was due to be completed on February 14, 2025, after the assessment and screening process was completed, however; the plan was completed on February 21, 2025.
Client # 6 was admitted to the partial hospitalization activity on August 29, 2024 and was discharged on September 12, 2024. The individual treatment and rehabilitation plan was due to be completed on August 30, 2024, after the assessment and screening process was completed, however; the plan was completed on September 3, 2024.
Client # 7 was admitted to the partial hospitalization activity on August 16, 2024 and was discharged on September 5, 2024. The individual treatment and rehabilitation plan was due to be completed on August 16, 2024, after the assessment and screening process was completed, however; the plan was completed on August 21, 2025.
Client # 11 was admitted to the outpatient activity on December 19, 2024 and was discharged on March 17, 2025. The individual treatment and rehabilitation plan was due to be completed on December 22, 2024, after the assessment and screening process was completed, however; the plan was completed on December 23, 2024.
Client # 14 was admitted to the outpatient activity on November 1, 2024 and was discharged on November 14, 2024. The individual treatment and rehabilitation plan was due to be completed on November 1, 2024, after the assessment and screening process was completed, however; the plan was completed on November 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s). The Master Treatment Plan policy and procedure will be updated to specify the timeframe of 72 hours for completion of the individual treatment and rehabilitation plan (master treatment plan). This policy and procedure update will be communicated to staff. To ensure ongoing compliance chart audits will continue to check for completion of the master treatment plan within the 72 hours timeframe. Corrective action date is set for 7/1/2025. |
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 disclosed on consent to release information forms in fourteen of fourteen applicable client records reviewed.
Client #1 was admitted to the partial hospitalization activity on March 11, 2025 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on March 11, 2025, did not include the specific information to be disclosed.
Client #2 was admitted to the partial hospitalization activity on November 6, 2024 and was discharged on November 21, 2024. The release of information form to a urinalysis lab, signed and dated by the client on November 6, 2024, did not include the specific information to be disclosed.
Client #3 was admitted to the partial hospitalization activity on March 17, 2025 and was discharged on March 28, 2025. The release of information form to a urinalysis lab, signed and dated by the client on December 19, 2024, did not include the specific information to be disclosed.
Client #4 was admitted to the partial hospitalization activity on January 23, 2025 and was discharged on February 6, 2025. The release of information form to a urinalysis lab, signed and dated by the client on January 23, 2025, did not include the specific information to be disclosed.
Client #5 was admitted to the partial hospitalization activity on February 13, 2025 and was discharged on February 28, 2025. The release of information form to a urinalysis lab, signed and dated by the client on February 13, 2025, did not include the specific information to be disclosed.
Client #6 was admitted to the partial hospitalization activity on August 29, 2024 and was discharged on September 12, 2024. The release of information form to a urinalysis lab, signed and dated by the client on August 29, 2024, did not include the specific information to be disclosed.
Client #7 was admitted to the partial hospitalization activity on August 16, 2024 and was discharged on September 5, 2024. The release of information form to a urinalysis lab, signed and dated by the client on May 14, 2024, did not include the specific information to be disclosed.
Client #8 was admitted to the outpatient activity on December 6, 2024 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on November 6, 2024, did not include the specific information to be disclosed.
Client #9 was admitted to the outpatient activity on February 26, 2025 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on January 23, 2025, did not include the specific information to be disclosed.
Client #10 was admitted to the outpatient activity on October 17, 2024 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on October 17, 2024, did not include the specific information to be disclosed.
Client #11 was admitted to the outpatient activity on December 19, 2024 and was discharged on March 17, 2025. The release of information form to a urinalysis lab, signed and dated by the client on December 19, 2024, did not include the specific information to be disclosed.
Client #12 was admitted to the outpatient activity on January 13, 2025 and was discharged on February 27, 2025. The release of information form to a urinalysis lab, signed and dated by the client on January 13, 2025, did not include the specific information to be disclosed.
Client #13 was admitted to the outpatient activity on July 30, 2024 and was discharged on October 3, 2024. The release of information form to a urinalysis lab, signed and dated by the client on July 30, 2024, did not include the specific information to be disclosed.
Client #14 was admitted to the outpatient activity on November 1, 2024 and was discharged on January 14, 2025. The release of information form to a urinalysis lab, signed and dated by the client on November 1, 2024, did not include the specific information to be disclosed.
This is a repeat citation from the April 30, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s). The two release of information consents for the urinalysis lab will be updated to include a section for items to be disclosed. There will be communication of this update to the employees. To ensure ongoing compliance chart audits will continue to be completed and check for proper completion of consent forms. All new ROI's with required items will be reviewed and completed with the current clients listed in the deficiency by 4/30/2025. Corrective action date is set for 7/1/2025. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire on consent to release information forms in fourteen of fourteen applicable client records reviewed.
Client #1 was admitted to the partial hospitalization activity on March 11, 2025 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on March 11, 2025, did not include the date, event, or condition upon which the consent will expire.
Client #2 was admitted to the partial hospitalization activity on November 6, 2024 and was discharged on November 21, 2024. The release of information form to a urinalysis lab, signed and dated by the client on November 6, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #3 was admitted to the partial hospitalization activity on March 17, 2025 and was discharged on March 28, 2025. The release of information form to a urinalysis lab, signed and dated by the client on December 19, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #4 was admitted to the partial hospitalization activity on January 23, 2025 and was discharged on February 6, 2025. The release of information form to a urinalysis lab, signed and dated by the client on January 23, 2025, did not include the date, event, or condition upon which the consent will expire.
Client #5 was admitted to the partial hospitalization activity on February 13, 2025 and was discharged on February 28, 2025. The release of information form to a urinalysis lab, signed and dated by the client on February 13, 2025, did not include the date, event, or condition upon which the consent will expire.
Client #6 was admitted to the partial hospitalization activity on August 29, 2024 and was discharged on September 12, 2024. The release of information form to a urinalysis lab, signed and dated by the client on August 29, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #7 was admitted to the partial hospitalization activity on August 16, 2024 and was discharged on September 5, 2024. The release of information form to a urinalysis lab, signed and dated by the client on May 14, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #8 was admitted to the outpatient activity on December 6, 2024 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on November 6, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #9 was admitted to the outpatient activity on February 26, 2025 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on January 23, 2025, did not include the date, event, or condition upon which the consent will expire.
Client #10 was admitted to the outpatient activity on October 17, 2024 and was still active at the time of the inspection. The release of information form to a urinalysis lab, signed and dated by the client on October 17, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #11 was admitted to the outpatient activity on December 19, 2024 and was discharged on March 17, 2025. The release of information form to a urinalysis lab, signed and dated by the client on December 19, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #12 was admitted to the outpatient activity on January 13, 2025 and was discharged on February 27, 2025. The release of information form to a urinalysis lab, signed and dated by the client on January 13, 2025, did not include the date, event, or condition upon which the consent will expire.
Client #13 was admitted to the outpatient activity on July 30, 2024 and was discharged on October 3, 2024. The release of information form to a urinalysis lab, signed and dated by the client on July 30, 2024, did not include the date, event, or condition upon which the consent will expire.
Client #14 was admitted to the outpatient activity on November 1, 2024 and was discharged on January 14, 2025. The release of information form to a urinalysis lab, signed and dated by the client on November 1, 2024, did not include the date, event, or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s). All required consents will be updated to include a date, event, or condition for which the consent will expire. There will be communication of this update to the employees. To ensure ongoing compliance chart audits will continue to be completed and check for proper completion of consent forms. All new ROI's with required items will be reviewed and completed with the current clients listed in the deficiency by 4/30/2025. Corrective action date is set for 7/1/2025. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review and a review of client records, the facility failed to develop a recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance.
On April 1, 2025, the DDAP representative had provided the facility with a list of items, including the list of clients who were discharged since the previous licensing inspection, to have ready and available on the days of this inspection, which was April 3, 2025 through April 4, 2025. On April 3, 2025, the DDAP Representative attempted to review the discharged clients from the provided list and discovered that several clients on the list were discharged from the provider's other treatment facility located in another state.
The DDAP representative requested an updated list be provided that only consisted of clients who were discharged from the facility DDAP licenses and is currently being inspected. A second discharged client list was provided on April 4, 2025 and, again, there were several clients on the second list who were discharged from the out-of-state treatment facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Chief Compliance Officer met to review the finding and regulation(s). The Executive Director and Chief Compliance Officer will review all active client charts to ensure they have the correct location listed. To ensure ongoing compliance chart audits will continue to be completed and check for proper facility location to be listed. Corrective Action Date is set for 7/1/2025. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in two of two applicable client records reviewed.
Client # 12 was admitted to the outpatient activity on January 13, 2025 and was administratively discharged on February 27, 2025. The client was notified, in writing, of the decision to involuntarily terminate their treatment at the project; however, there was no documentation of the reason for termination included on the written notification.
Client # 15 was admitted to the outpatient activity on May 28, 2024 and was administratively discharged on August 6, 2024. The client was notified, in writing, of the decision to involuntarily terminate the client ' s treatment at the project; however, there was no documentation of the reason for termination included on the written notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s).The Termination Appeal Letter to the clients will be updated to include the reason for termination. There will be communication of this update to the employees. To ensure ongoing compliance chart audits will be completed and include checking for the correct termination appeal letter if applicable to the client. Corrective action date is set for 7/1/2025. |
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 the documentation of follow-up information, in two of four applicable records reviewed.
Client # 11 was admitted to the outpatient activity on December 19, 2024 and was discharged on March 17, 2025. There was no documentation of follow-up information in the record at the time of the inspection.
Client # 14 was admitted to the outpatient activity on November 1, 2024 and was discharged on November 14, 2024. There was no documentation of follow-up information in the record at the time of the inspection.
This is a repeat citation from the April 30, 2024 and May 5, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s).Executive Director will meet with the staff and review the client follow-up procedures. Chart audits will continue to be completed and will check for client follow-up documentation when applicable in the clients chart. To ensure ongoing compliance chart audits will be completed and include checking for the follow-up documentation if applicable to the client. Corrective action date is set for 7/1/2025. |
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.
Plans of correction for failing to ensure clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months in the position were submitted and approved by the Department from the May 5, 2023 and April 30, 2024 annual licensing inspections. Failing to ensure clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months in the position was again found to be a deficiency in the April 3, 2025 through April 4, 2025 annual licensing inspection.
Plans of correction for failing to document follow-up information as part of a complete client record were submitted and approved by the Department from the May 5, 2023 and April 30, 2024 annual licensing inspections. Failing to document follow-up information as part of a complete client record was again found to be a deficiency in the April 3, 2025 through April 4, 2025 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Chief Compliance Officer met to review finding and regulation(s). Executive Director and Chief Compliance Officer will create quarterly "DDAP POC meetings" to review and ensure all POC items are continued to be followed and/or are completed. To ensure ongoing compliance random audits over DDAP POC items will be completed and reviewed Corrective action date is set for November 2025. |