INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 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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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 August, 2025 - July, 2026, 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 August, 2025 through June, 2026.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 8/31/2026. The site administrative assistant in conjunction with the Facility Director will conduct monthly reviews of the Fire Drill logs to ensure ongoing compliance with 705.28 (d) (1).In lieu of an administrative assistant on staff, the lead counselor will be responsible to ensure that the fire drills occur and are recorded on a monthly basis. |
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 three out of seven applicable records reviewed.Client #5 was admitted on January 7, 2026 and was discharged on March 31, 2026. A comprehensive treatment plan was completed on January 21, 2026 and an update was due no later than March 23, 2026; however, none was completed.Client #6 was admitted on August 25, 2025 and was discharged on February 16, 2026. A treatment plan update was completed on October 23, 2025 and the next update was due no later than December 23, 2025; however, it was not completed until January 5, 2026.Client #7 was admitted on August 19, 2025 and was discharged on May 19, 2026. A treatment plan update was completed on November 20, 2025 and the next update was due no later than January 20, 2026; however, it was not completed until February 13, 2026.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 6, 2022, July 18, 2023, July 23, 2024 and August 14, 2025 annual licensing inspections.
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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)(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.
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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 two out of three records reviewed. Client #6 was admitted on August 25, 2025 and was discharged on February 16, 2026. No discharge summary was completed.Client #7 was admitted on August 19, 2025 and was discharged on May 19, 2026. No discharge summary was completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Documented review of 709.93(a) (10) will be completed with all counselors by 8/31/2026. A discharge summary for client #6 was completed on 7/30/2026, and a discharge summary for client #7 was completed on 8/17/2026. To ensure ongoing compliance with 709.93(a)(10), a bi-weekly audit will be conducted by the primary counselor in conjunction with the Facility Director to monitor the timely completion of discharge summaries. |
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 a plans of correction that were approved by the Department. A plan of correction for treatment plan updates was submitted and approved by the Department for the September 6, 2022, July 18, 2023, July 23, 2024 and August 14, 2025 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the July 29, 2026 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 8/31/2026. To ensure ongoing compliance with 709.17(a) (3),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 counselor supervision meetings. Staff progressive disciplinary action including but not limited to verbal and written warnings, and termination, will be instituted moving forward for non-compliance with department and center guidelines. |