INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 2024 and April 30, 2024, 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in two of two applicable personnel records reviewed.
Employee #3 was hired as a clinical supervisor on December 1, 2022 and did not have 2 years of clinical supervision experience documented prior to being hired. There was no documentation of the clinical supervision core curriculum training being completed at the time of the inspection.
Employee #4 was hired as a lead counselor on October 7, 2022 and did not have 2 years of clinical supervision experience documented prior to being hired. There was no documentation of the clinical supervision core curriculum training being completed at the time of the inspection.
This is a repeat citation from the May 5, 2023 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 will meet to review the employee training plan to ensure it included all required core curriculum in clinical supervision, timeframes, and the documentation for completion. Completion of core curriculum in clinical supervision to applicable staff will be by 6/25/2024. To ensure compliance the Executive Director will track the progress of completion with required staff and update the employee treatment plan for employee file by 6/25/2024. |
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 that 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 December 1, 2022. There was 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 annual licensing renewal 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 will meet to review employee training plans to ensure it includes all required supervisions needed in first 6 months of employment in applicable positions. The Executive Director will ensure all meeting minute requirements are held with applicable staff, documented, and completed within the required timeframe of 6 months in the employee training plan. Current employees will be in required compliance by 12/1/2024. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy manual, the project director failed to include documentation of how staff training needs would be assessed, who is responsible, and the timeframes for completion within the project's comprehensive staff development program.
This is a repeat citation from the May 5, 2023 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 will met to review and update the current policy and procedure to accurately identify how training requirements are assessed, staff responsible and the timeframes for completion. The policy and procedure will be updated and reviewed with staff by 6/25/2024. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy manual, the project director failed to include documentation of an overall plan for addressing staff training needs, who is responsible, and the timeframes for completion within the project's comprehensive staff development program.
This is a repeat citation from the May 5, 2023 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 will meet to review and update the current policy and procedure to accurately identify how training requirements are assessed, staff responsible and the timeframes for completion. The policy and procedure will be updated and reviewed with staff by 6/25/2024. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the policy manual, the project director failed to include documentation of a mechanism to collect feedback on completed trainings, who is responsible, and the timeframes for completion within the project's comprehensive staff development program.
This is a repeat citation from the May 5, 2023 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 will meet to review and update the current policy and procedure to accurately identify a mechanism for collecting feedback on trainings including who is responsible and the timeframes for completion. The policy and procedure and forms will be updated and reviewed with staff by 6/25/2024. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy manual, the project director failed to include documentation of an annual evaluation of the overall staff training plan, who is responsible, and the timeframes for completion within the project's comprehensive staff development program.
This is a repeat citation from the May 5, 2023 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 will meet to review and update the current policy and procedure to accurately identify annual evaluations over employee training plans, who is responsible and the timeframes for completion. The policy and procedure will be updated and reviewed with staff by 6/25/2024. |
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 within the regulatory time frame in two of two applicable personnel record reviewed.
Employee #4 was hired as a lead counselor on October 7, 2022. The HIV/AIDS and TB/STD trainings were due no later than October 23, 2023; however, both trainings were not completed as of the date of the inspection.
Employee #5 was hired as a counselor on April 17, 2023. The TB/STD training was due no later than April 17, 2024; however, the training was not completed as of the date of the inspection.
This is a repeat citation from the May 5, 2023 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 current employee training plans to ensure staff are meeting required training requirements for 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics in appropriate timeframes. All employee training plans out of compliance will complete these trainings by 6/25/2024.
To ensure compliance The Executive Director will monitor the completion of the required trainings.
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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's May 2023 through March 2024 fire drill logs, the facility failed to ensure that the written fire drill logs included the exit route used during fire drills.
The December 2023 fire drill log did not include which exit route was used during the drill.
This is a repeat citation from the May 5, 2023 annual licensing renewal 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 requirements for fire safety and proper completion. To ensure ongoing compliance the Executive Director will complete the fire drill forms and submit them to the compliance department monthly, the compliance department will check for proper completion effective May 2024. |
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 two of thirteen records reviewed.
Client #2 was admitted to the outpatient level of care on October 30, 2023 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 #4 was admitted to the outpatient level of care on July 26, 2023 and was discharged on September 14, 2023. 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.
This is a repeat citation from the May 5, 2023 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 Lead Therapist met to review requirements for consents and for proper completion. Lead therapist will train clinical staff on the consent requirements. To ensure ongoing compliance chart audits will be completed weekly by the Lead Therapist to monitor needed requirements and current client chart will be reviewed and updated by the Lead therapist by 6/25/2024.
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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 the disclosure was to be made to on a consent form in one of thirteen client records reviewed.
Client #2 was admitted to the outpatient level of care on October 30, 2023 and was still active at the time of inspection. A release of information form was signed and dated by the client on October 30, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made to.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Lead Therapist met to review requirements for consents and for proper completion. Lead therapist will train clinical staff on the consent requirements. To ensure ongoing compliance chart audits will be completed weekly by the Lead Therapist to monitor needed requirements and current client chart will be reviewed and updated by the Lead therapist by 6/25/2024.
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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 disclosed on a consent to release information form in one of thirteen client records reviewed.
Client #11 was admitted into the partial hospitalization level of care on July 13, 2023 and was discharged July 24, 2023. The release of information form to the funding source was signed and dated by the client on July 13, 2023; however, the form did not include the specific information to be released.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Lead Therapist met to review requirements for consents and proper completion. To ensure ongoing compliance the Lead Therapist will complete weekly chart audits and continue to monitor by 6/25/2024. |
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 client records, the facility failed to document the purpose of the disclosure on a release of information form in one of thirteen client records reviewed.
Client # 11 was admitted into the partial hospitalization level of care on July 13, 2023 and was discharged July 24, 2023. The release of information form to the funding source was signed and dated by the client on July 13, 2023; however, the form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Lead Therapist met to review requirements for consents and proper completion. To ensure ongoing compliance the Lead Therapist will complete weekly chart audits and continue to monitor by 6/25/2024. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of thirteen client records reviewed.
Client #4 was admitted to the outpatient level of care on July 26, 2023 and was discharged on September 14, 2023. A release of information form to an emergency contact was signed by a witness on July 26, 2023, but the form was not signed and dated by the client.
Client #5 was admitted to the outpatient level of care on July 31, 2023 and was discharged on October 3, 2023. A release of information form to an emergency contact was signed by a witness on July 31, 2023, but the form was not signed and dated by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Lead Therapist met to review requirements for consents and proper completion. To ensure ongoing compliance the Lead Therapist will complete weekly chart audits and continue to monitor by 6/25/2024. |
709.81(a)(3) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of the facility policy and procedure manual and the client handbook, the project director failed to include in their intake and admission written plan the requirements for completion of treatment in the partial hospitalization level of care.
This is a repeat citation from the May 5, 2023 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 the intake and admission regulations and the company's policy and procedures manual and client handbook. To ensure compliance these documents will be updated to include the requirements for completion of treatment and reviewed with staff by 6/25/2024. |
709.91(a)(3) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of the facility policy and procedure manual and the client handbook, the project director failed to include in their intake and admission written plan the requirements for completion of treatment in the outpatient level of care.
This is a repeat citation from the May 5, 2023 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 the intake and admission regulations and the company's policy and procedures manual and client handbook. To ensure compliance these documents will be updated to include the requirements for completion of treatment and reviewed with staff by 6/25/2024. |
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 60 days in three of five applicable client records reviewed.
Client #2 was admitted on October 30, 2023 and was still active at the time of inspection. The comprehensive treatment plan was completed on November 6, 2023 and an update was due no later than January 6, 2024; however, the update was not completed until February 15, 2024.
Client #6 was admitted on July 17, 2023 and was discharged on October 9, 2023. The comprehensive treatment plan was completed on July 20, 2023 and an update was due no later than September 20, 2023; however, the update was not completed prior to discharge.
Client #7 was admitted on October 23, 2023 and was discharged on January 3, 2024. The comprehensive treatment plan was completed on October 26, 2023 and an update was due no later than December 26, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Lead Therapist met to review requirements for treatment and rehabilitation services and proper completion. To ensure ongoing compliance the Lead Therapist will complete weekly chart audits and continue to monitor by 6/25/2024. |
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 follow-up information, in two of four applicable records reviewed.
Client #4 was admitted on July 26, 2023 and was discharged on September 14, 2023. There was no documentation of follow-up information in the record at the time of the inspection.
Client #7 was admitted on October 23, 2023 and was discharged on January 3, 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 May 5, 2023 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 Lead Therapist met to review requirements for client records and proper completion. To ensure ongoing compliance the Lead Therapist will review with clinical staff and complete weekly chart audits and continue to monitor by 6/25/2024. |