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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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 six out of six applicable records reviewed.
Client #1 was admitted on August 28, 2024and was still active at the time of the inspection. A treatment plan update was completed on December 18, 2025 and the next update was due no later than February 17, 2025; however, it was not completed until February 26, 2025.
Client #2 was admitted on November 21, 2024 and was still active at the time of the inspection. A treatment plan update was completed on January 15, 2025 and the next update was due no later than March 17, 2025; however, it was not completed until March 19, 2025.
Client #3 was admitted on July 24, 2024 and was still active at the time of the inspection. A treatment plan update was completed on June 4, 2025 and an update was due no later than August 4, 2025; however, none was completed.
Client #4 was admitted on July 17, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 28, 2025 and the next update was due no later than July 28, 2025; however, it was not completed until July 30, 2025.
Client #5 was admitted on May 15, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 13, 2025 and an update was due no later than July 13, 2025. However, it was not completed until July 18, 2025.
Client #7 was admitted on September 18, 2024 and was discharged on March 12, 2025. A treatment plan update was completed on December 18, 2024 and an update was due no later than February 18, 2025. 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 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 seven out of seven 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.
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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 two out of two 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 March 26, 2025 and discharged on May 5, 2025. A follow up was due no later than July 5, 2025; however, none was completed.
Client #7 was admitted on September 18, 2024 and discharged on March 12, 2025. A follow up was due no later than May 12, 2025; however, none was completed.
This finding was reviewed with facility staff during the licensing process.
This was a repeat citation from the July 24, 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 client #6 and #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 indicated in the facilities policy and procedures manual. |