INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 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:
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to have hot water under pressure in the second-floor bathroom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A documented review of 705.24(3) will be completed with administrative staff by 9/19/2025. A ticket will be submitted to our operations department requesting repair of the hot water faucet in the second-floor bathroom on 9/3/2025 to be completed no later than 9/30/2025. To ensure ongoing compliance with 705. 24(3), administrative staff will begin conducting weekly facility walk-throughs to ensure that hot and cold water are available in all bathrooms. |
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 fire drill logs from July, 2024 - July, 2025, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of December, 2024 and February 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Documented education will be provided to staff regarding 705.28 (d) (1) by 9/19/2025.The Clinical Supervisor in conjunction with the Facility Director will conduct monthly reviews of the Fire Drill logs to ensure ongoing compliance with 705.28 (d) (1). |
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 July, 2024 through July, 2025 fire drill logs during the inspection, the facility failed to document the time, the time it took for evacuation and the number of persons in the facility at the time of the drill during the March, 2025 drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Documented education will be provided to staff regarding 705.28 (d)(4) by 9/19/2025.The Clinical Supervisor in conjunction with the Facility Director will conduct monthly reviews of the Fire Drill logs to ensure ongoing compliance with 705.28 (d)(4). |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of seven applicable records reviewed.
Client #1 was admitted on January 27, 2025 and was still active at the time of the inspection. A treatment plan update was completed on May 23, 2025 and the next update was due no later than July 23, 2025; however, it was not completed until August 1, 2025.
Client #2 was admitted on May 31, 2024 and was still active at the time of the inspection. A treatment plan update was completed on April 11, 2025 and the next update was due no later than June 11, 2025; however, it was not completed until July 29, 2025.
Client #3 was admitted on August 29, 2024 and was still active at the time of the inspection. A treatment plan update was completed on April 10, 2025 and an update was due no later than June 10, 2025; however, it was not completed until June 12, 2025.
Client #4 was admitted on March 21, 2023 and was still active at the time of the inspection. A treatment plan update was completed on November 7, 2024 and the next update was due no later than January 7, 2025; however, it was not completed until February 6, 2025.
Client #7 was admitted on November 1, 2024 and was discharged on March 3, 2025. A comprehensive treatment plan was completed on November 24, 2024 and an update was due no later than January 24, 2025. However, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 23, 2024, July 18, 2023 and September 9, 2022 annual licensing inspections.
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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)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in eight out of eight applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 60 days following admission.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 18, 2023 licensing inspection.
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Plan of Correction
A Documented review of 709.93(a)(8) will be completed with treatment staff by 9/19/2025. To ensure ongoing compliance with, 709.93(a)(8) a monthly audit will be conducted by the Clinical Supervisor in conjunction with the Facility Director to monitor the completion of case consultation notes every 60-days following admission in accordance with the facilities policy and procedure manual. |
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 document follow up information within guidelines established by the facility's policy and procedures manual in three out of four applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 60 days following discharge.
Client #6 was admitted on February 17, 2025 and discharged on May 23, 2025. A follow up was due no later than July 23, 2025; however, none was completed.
Client #7 was admitted on November 1, 2024 and discharged on March 3, 2025. A follow up was due no later than May 3, 2025; however, none was completed.
Client #8 was admitted on July 5, 2024 and discharged on March 3, 2025. A follow up was due no later than May 3, 2025; however, none was completed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the August 9, 2021, September 6, 2022, July 18, 2023 and July 23, 2024 licensing inspection.
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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 clients #6-#8 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 indicated in the facilities policy and procedures manual. |
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 staff client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates were submitted and approved by the Department for the September 6, 2022, July 18, 2023 and July 23, 2024 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the August 14, 2025 licensing inspection.
A plan of correction for follow ups were submitted and approved by the Department for the August 9, 2021, September 6, 2022, July 18, 2023 and July 23, 2024 annual licensing inspections. Follow ups were again found to be a deficiency in the August 14, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Documented review of 709.17(a)(3) will be completed with all treatment staff by 9/19/2025. To ensure ongoing compliance with 709.17(a)(3),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. Additionally, staff progressive disciplinary action will be instituted moving forward for non-compliance with department and center guidelines. |