INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2026 through April 30, 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 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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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from clients prior to the disclosure of information in three of thirteen records reviewed.
Client # 3 was admitted to the outpatient activity on January 12, 2026 and was still active at the time of inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 9 was admitted to the partial hospitalization activity on July 23, 2025 and was discharged on August 13, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, the consent to release information form was not signed by the client until August 27, 2025
Client # 11 was admitted to the partial hospitalization activity on January 12, 2026 and was discharged on January 30, 2026. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Supervisor met to review finding. Executive Director and Clinical Supervisor reviewed how to properly complete consent forms and timeline requirements with the staff during all staff meeting and emails on 5/14/2026. To ensure ongoing compliance charts audits will continue to be completed by clinical staff and submitted to the Clinical Supervisor for review of successfully completed consent forms. All corrective actions were completed on 5/14/2026. |
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 three of thirteen client records reviewed.
Client # 1 was admitted to the outpatient activity on December 8, 2025 and was still active at the time of inspection. The release of information forms to a funding source and an emergency contact that were signed and dated by the client on February 26, 2026 did not include the specific information to be disclosed next to the space that was marked as "other".
Client # 7 was admitted to the outpatient activity on February 24, 2026 and was discharged on March 5, 2026. The release of information form to a funding source that was signed and dated by the client on February 24, 2026 did not include the specific information to be disclosed next to the space that was marked as "other".
Client # 10 was admitted to the partial hospitalization activity on January 5, 2026 and was discharged on January 20, 2026. The release of information form to a funding source that was signed and dated by the client on January 6, 2026 did not include the specific information to be disclosed next to the space that was marked as "other".
This is a repeat citation from the April 30, 2024 and April 4, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Supervisor met to review finding. Executive Director and Clinical Supervisor reviewed how to properly complete consent release of information forms and timeline requirements with the staff during all staff meeting and emails on 5/14/2026. To ensure ongoing compliance charts audits will continue to be completed by clinical staff and submitted to the Clinical Supervisor for review of successfully completed consent release of information forms. All corrective actions were completed on 5/14/2026. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to ensure the documentation of the written acknowledgment by clients that they have been notified of their regulatory client rights in thirteen of thirteen client records reviewed.
In every client record reviewed, there was a client rights acknowledgement form, which was signed by each client; however, all the regulatory-required client rights were not included on the acknowledgement form. There was no other documentation in the record indicating the client rights were acknowledged to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Compliance Officer and Executive Director met to review the finding. Chief Compliance Officer reviewed and updated the client rights consent form and client handbook to include the missing regulatory client rights on 4/30/2026. Executive Director reviewed these updates with the staff in the all staff meeting on 5/14/2026. To ensure ongoing compliance weekly chart audits will continue to be completed and submitted to ensure the client rights consent form and client handbooks are being reviewed and completed with clients. |
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 the review of client records, the project failed to ensure all treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of three applicable client records reviewed.
Client # 2 was admitted to the outpatient activity on December 8, 2025 and was active at the time of the inspection. A treatment and rehabilitation plan update was completed on January 19, 2026 and the next update was due no later than March 19, 2026; however, the update was completed on March 26, 2026.
Client # 5 was admitted to the outpatient activity on August 7, 2025 and was discharged on December 3, 2025. The comprehensive treatment and rehabilitation plan was completed on August 20, 2025 and the first update was due no later than October 20, 2025; however the update was completed on October 24, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Supervisor met to review finding. Executive Director and Clinical Supervisor reviewed how to properly complete treatment and rehabilitation plans and timeline requirements with the staff during all staff meeting and emails on 5/14/2026. To ensure ongoing compliance charts audits will continue to be completed by clinical staff and submitted to the Clinical Supervisor for review of successfully completed treatment and rehabilitation plans within timeframes. All corrective actions were completed on 5/14/2026. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
Based on the review of client records, the project failed to provide the authorized Department representative with full and free access to the records of the facility and its clients.
On April 29, 2026, the facility provided a list of clients admitted to the program. During the inspection of client records, the Department representative was unable to access the record of one of the clients from the provided list as the electronic system used by the facility did not grant access to the client's record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Compliance Officer and Executive Director met to review finding. Chief Compliance Officer reached out and placed a service ticket to the electronic medical records system to ensure all required access to records was completed on 5/14/2026. To ensure ongoing compliance Executive Director will run reports monthly in the system to ensure all required access to client records are available. All corrective actions completed on 5/14/2026. |
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 corrections for failing to document the specific information to be disclosed on consent to release information forms were submitted and approved by the Department from the April 30, 2024 and April 4, 2025 annual licensing inspections. Failing to document the specific information to be disclosed on consent to release information forms was again found to be a deficiency in the April 29, 2026 through April 30, 2026 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Compliance Officer, Executive Director and Clinical Supervisor met to review finding. Executive Director and Clinical Supervisor reviewed how to properly complete consent release of information forms and timeline requirements with the staff during all staff meeting and emails on 5/14/2026. To ensure ongoing compliance charts audits will continue to be completed by clinical staff and submitted to the Clinical Supervisor for review of successfully completed consent release of information forms and the Executive Director will complete random chart audits to also ensure the plan of corrections is being followed. All corrective actions were implemented and completed on 5/14/2026. |