INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to maintain the grounds in a safe manner. It was observed that the deck of the side porch had holes in it.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A documented review of 705.22(2) will be completed with all administrative staff by 9/19/2025. A maintenance ticket for repair of the side porch will be submitted on 9/3/2025, with repairs expected to be completed by 9/30/2025. To ensure ongoing compliance, administrative staff will begin conducting weekly facility walk-throughs to ensure that buildings and grounds are clean, safe, sanitary and in good repair at all times. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. The basement did not have a fire extinguisher.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A documented review of 705.28 (b)(1) will be completed with all administrative staff by 9/19/2025. The office administrator will contact the fire extinguisher inspection company, S.A. Comunale no later 9/22/2025 to request a replacement extinguisher. To ensure ongoing compliance, administrative staff will begin conducting quarterly fire extinguisher checks to ensure compliance with 705.28 (b)(1). |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #7 was hired on August 19, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on May 26, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A documented review of 705.28 (c)(4) will be completed with all treatment staff by 9/19/2025. To ensure ongoing compliance with 705. 28(c)(4), the Clinical Supervisor in conjunction with the Facility Director will complete the HR provided employee onboarding checklist to ensure compliance with all required trainings within the 7-day period following hire in accordance with 705.28(c)(4). |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #7 was hired on August 19, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on May 26, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A documented review of 705.28 (c)(4) will be completed with all treatment staff by 9/19/2025. To ensure ongoing compliance with 705. 28(c)(4), the Clinical Supervisor in conjunction with the Facility Director will complete the HR provided employee onboarding checklist to ensure compliance with all required trainings within the 7-day period following hire in accordance with 705.28(c)(4). |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in four out of seven applicable records reviewed.
Client #2 was admitted on January 30, 2025 and was still active at the time of the inspection. The treatment plan was dated February 5, 2025.
Client #3 was admitted on February 4, 2025 and was still active at the time of the inspection. The treatment plan was dated February 14, 2025.
Client #4 was admitted on December 5, 2024 and was still active at the time of the inspection. The treatment plan was dated December 19, 2024.
Client #5 was admitted on October 29, 2024 and was discharged on April 29, 2025. The treatment plan was dated November 13, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A Documented review of 709.92(a)(3) will be completed with all counselors by 9/19/2025. Treatment plans will be updated for clients # 2, #3, and #4 to include proposed support services by 9/30/2025. To ensure ongoing compliance with 709.92(a)(3), a bi-weekly audit will be conducted by the Clinical Supervisor in conjunction with the Facility Director of all completed Master Treatment Plans for the previous 2-week period to ensure the inclusion of proposed support services. The results of said audits will be shared with counseling staff during individual supervision with either the Clinical Supervisor or the Facility Director. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of seven applicable records reviewed.
Client #1 was admitted on March 17, 2025 and was still active at the time of the inspection. The treatment plan dated May 30,2025 stated one individual session per week. Individual sessions only occurred on June 19, 2025 and July 15, 2025.
Client #2 was admitted on January 30, 2025 and was still active at the time of the inspection. The treatment plan dated May 20, 2025 and June 30, 2025 stated two groups per week and one individual session bi-weekly. Groups occurred on July 22, 23, 29, 30 and August 5, 2025. Individual sessions occurred on July 14, 2025.
Client #3 was admitted on February 4, 2025 and was still active at the time of the inspection. The treatment plan dated July 15, 2025 stated three groups per week and one individual session bi-weekly. Groups only occurred on July 29, 30 and August 5, 2025. The only individual session occurred on July 15, 2025.
Client #5 was admitted on October 29, 2024 and was discharged on April 29, 2025. The treatment plan dated March 6, 2025 stated three groups per week and one individual bi-weekly. Groups occurred on March 25, April 1, April 8, April 14, and April 22, 2025. Individual session occurred on March 3, 25 and April 29, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A documented review of 709.92 (c) will be completed with all staff by 9/19/2025. Client records #1-#3 will be updated to reflect actual type and frequency of service provision by 9/30/2025. To ensure ongoing compliance with 709.92(c), a bi-weekly audit of all client treatment plans and appointment records will be conducted by the Clinical Supervisor in conjunction with the Facility Director to monitor for alignment between type and frequency of services recommended versus services received. The Clinical Supervisor in conjunction with the Facility Director will review any discrepancies found during the audit process with counseling staff immediately upon discovery and will work with both the counselor and the client to ensure compliance with stated type and frequency of service provision. |
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 outpatient 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 thereafter.
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. |