INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 12, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Naaman 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:
|
Plan of Correction
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill logs from August, 2024 - July 2025, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit routes.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facility Director and the DDAP Licensing Specialist reviewed the need to utilize alternate exit routes during fire drills with location staff on 8/12/2025.The staff member identified an alternate exit at that time and will begin utilizing alternate exit locations each month when the drill is performed, beginning with the September 2025 fire drill. The fire drill log will be reviewed by the Clinical Supervisor in conjunction with the Facility Director on a monthly basis to ensure ongoing compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the August, 2024 through July, 2025 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the July 25, 2024 licensing inspection
|
Plan of Correction
A review of the need for use of alternate means of fire drill notification was reviewed with staff on 8/12/2025. On 8/12/2025 a verbal request was made to the Director of Compliance to submit a waiver requesting permission to use a cell phone alarm as the notification method for fire drills. A follow-up request was initiated on 8/27/2025 and 9/3/2025. On 9/4/2025 a waiver request was submitted to The Department of Drug and Alcohol Programs by the Director of Compliance and as of the date of this POC we are still awaiting a response. Effective immediately the office staff has been directed to begin using an alarm on her cell phone to alert for a drill, and to note on the said alarm on the fire drill log. The fire drill log will be reviewed by the Clinical Supervisor in conjunction with the Facility Director on a monthly basis to ensure ongoing compliance. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of three applicable records reviewed.
Client #4 was admitted on March 4, 2025 and discharged on June 3, 2025. A comprehensive treatment plan was completed on March 12, 2025 and an update was due no later than May 12, 2025; however, none was completed.
Client #6 was admitted on May 15, 2024 and discharged on February 25, 2025. A treatment plan update was completed on November 5, 2024 and an update was due no later than January 4, 2025; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 25, 2024 licensing inspection
|
Plan of Correction
A Documented review of 709.92(b) will be completed with all counselors by 9/19/2025. To ensure ongoing compliance with 709.92(b), a bi-weekly audit of all client treatment plans will be conducted by the Clinical Supervisor in conjunction with the Facility Director to monitor for those plans approaching their end date. The Clinical Supervisor in conjunction with the Facility Director will provide each counselor with a list of upcoming treatment plan updates at the time of the audit and will review all client treatment plans individually during counselor supervision meetings. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in five out of seven records reviewed.
Client #2 was admitted on February 19, 2025 and was discharged on April 11, 2025.
Client #3 was admitted on January 22, 2025 and was discharged on March 3, 2025.
Client #5 was admitted on December 10, 2024 and was discharged on February 25, 2025.
Client #6 was admitted on May 15, 2024 and discharged on February 25, 2025.
Client #7 was admitted on November 19, 2024 and was discharged on February 25, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 25, 2024 licensing inspection.
|
Plan of Correction
A Documented review of 709.93(a)(10) will be completed with all counselors by 9/19/2025. A discharge summary for Clients #2, #3, #5, #6, and #7 will be completed by 9/30/2025. To ensure ongoing compliance with 709.93(a)(10), a bi-weekly audit will be conducted by the Clinical Supervisor in conjunction with the Facility Director to monitor the timely completion of discharge summaries. |
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.
|
Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in six out of six applicable records reviewed. The facility's policy and procedures manual states the follow up must be completed 60 days following discharge.
Client #2 was admitted on February 19, 2025 and was discharged on April 11, 2025.
Client #3 was admitted on January 22, 2025 and was discharged on March 3, 2025.
Client #4 was admitted on March 4, 2025 and was discharged on June 3, 2025.
Client #5 was admitted on December 10, 2024 and was discharged on February 25, 2025.
Client #6 was admitted on May 15, 2024 and discharged on February 25, 2025.
Client #7 was admitted on November 19, 2024 and was discharged on February 25, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 25, 2024 licensing inspection.
|
Plan of Correction
A Documented review of 709.93(a)(11) will be completed with all counselors by 9/19/2025. Documented follow-up information for client #2-#7 will be completed by 9/30/2025. To ensure ongoing compliance with 709.93(a)(11), a monthly audit will be conducted by the Clinical Supervisor in conjunction with the Facility Director to monitor the completion of client follow-up within in the 60-day time frame as indicated in the facilities policy and procedures manual.
|