INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 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, 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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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 four out of seven applicable records reviewed.Client #2 was admitted on March 17, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 1, 2026 and an update was due no later than June 1, 2026; however, it was not completed until June 8, 2026.Client #3 was admitted on April 16, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 28, 2026 and an update was due no later than June 28, 2026: however, it was not completed until July 6, 2026.Client #4 was admitted on March 9, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 16, 2026 and an update was due no later than May 16, 2026: however, it was not completed until May 22, 2026. Additionally, the next update was due no later than July 22, 2026; however, none was completed.Client #7 was admitted on September 15, 2025 and was discharged on April 24, 2026. A treatment plan update was completed on January 20, 2026 and the next update was due no later than March 20, 2026; however,none was completed.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A Documented review of 709.92(b) will be completed with all counselors by 8/31/2026. To ensure ongoing compliance with 709.92(b), a bi-weekly audit of all client treatment plans will be conducted by the primary counselor in conjunction with the Facility Director to monitor for those plans approaching their end date. During bi-weekly individual supervision with each primary counselor the Facility Director will provide each counselor with a list of upcoming treatment plan updates for the next 2-week period and will review client treatment plans individually during individual 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 four out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed at time of intake and then every 60 days.Client #2 was admitted on March 17, 2026 and was still active at the time of the inspection. A case consultation was completed on March 17, 2026 and the next case consultation was due no later than May 17, 2026; however, it was not completed until June 9, 2026.Client #3 was admitted on April 16, 2026 and was still active at the time of the inspection. A case consultation was completed on April 16, 2026 and an update was due no later than June 16, 2026; however, none was completed.Client #4 was admitted on March 9, 2026 and was still active at the time of the inspection. A case consultation was completed on March 9, 2026 and an update was due no later than May 9, 2026; however, none was completed.Client #7 was admitted on September 15, 2025 and was discharged on April 24, 2026. A case consultation was completed on September 15, 2025 and the next update was due no later than November 15, 2025; however, it was not completed until April 24, 2026.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the August 15, 2025 licensing inspection.
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Plan of Correction
A Documented review of 709.93(a)(8) will be completed with treatment staff by 8/31/2026. To ensure ongoing compliance with, 709.93(a)(8) a monthly audit will be conducted by the primary counselor 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 one out of three applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed 60 days following discharge.Client #7 was admitted on September 15, 2025 and was discharged on April 24, 2026. A follow-up was due no later than June 24, 2026; however, none was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Documented review of 709.93(a) (11) will be completed with all counselors by 8/31/2026. Documented follow-up information for client #7 was completed on 8/10/2026. To ensure ongoing compliance with 709.93(a)(11), a monthly audit will be conducted by administrative assistant 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. |