INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 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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705.28 (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 month of 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). |
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 three out of six records reviewed.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. The treatment plan was dated February 26, 2025.
Client #2 was admitted on March 5, 2025 and was still active at the time of the inspection. The treatment plan was dated March 18, 2025.
Client #4 was admitted on March 19, 2025 and was still active at the time of the inspection. The treatment plan was dated March 26, 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(a)(3) will be completed with all counselors by 9/19/2025. Treatment plans will be updated for clients # 1, #2, 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(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 six records reviewed.
Client #3 was admitted on April 21, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 23, 2025 and an update was due no later than June 23, 2025; however, it was not completed until July 1, 2025.
Client #4 was admitted on March 19, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 26, 2025 and an update was due no later than May 26, 2025; however, it was not completed until May 28, 2025. Additionally, the next update was due no later than July 28, 2025; however, it was not completed until July 31, 2025.
Client #5 was admitted on July 30, 2024 and was discharged on July 8, 2025. A treatment plan update was completed on September 10, 2024 and an update was due no later than November 10, 2024; however, it was not completed until December 5, 2024. Additionally, an update was completed on January 9, 2025 and the next update was due no later than March 11, 2025; however, it was not completed until March 13, 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(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. |
709.92(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 seven out of seven applicable records reviewed.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. The treatment plan dated June 18,2025 stated three groups per week and one individual session per week. As of June 18, 2025 there have been no sessions.
Client #2 was admitted on March 5, 2025 and was still active at the time of the inspection. The treatment plan dated July 1, 2025 stated three groups per week and one individual session per week. The last individual session was July 1, 2025.
Client #3 was admitted on April 21, 2025 and was still active at the time of the inspection. The treatment plan dated July 1, 2025 stated one group per week and one individual session bi-weekly. Groups only occurred on July 7, 2025 and July 21, 2025.
Client #4 was admitted on March 19, 2025 and was still active at the time of the inspection. The treatment plan dated May 28, 2025 stated one group per week and one individual session bi-weekly. Groups have not occurred, and one individual session occurred on July 30, 2025.
Client #5 was admitted on July 30, 2024 and was discharged on July 8, 2025. The treatment plan dated May 8, 2025 stated one group per week. The only group was on June 5, 2025.
Client #6 was admitted on February 26, 2025 and was discharged on May 6, 2025. The treatment plan dated March 11, 2025 stated one group and one individual session per week. There were no groups or individual session the week of April 28, 2025.
Client #7 was admitted on August 24, 2023 and discharged on March 25, 2025. The treatment plan dated January 12, 2025 stated one individual session per week. Individual sessions only occurred on January 16, 2025 and February 6, 2025.
This finding was 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-#4 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 five out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed at intake and every 60 days thereafter.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. A case consultation was completed on February 12, 2025 and the next one was to be completed no later than April 14, 2025; however, it was not completed until June 18, 2025.
Client #2 was admitted on March 5, 2025 and was still active at the time of the inspection. A case consultation was completed on March 18, 2025 and the next one was due no later than May 18, 2025; however, none was completed.
Client #4 was admitted on March 19, 2025 and was still active at the time of the inspection. A case consultation was completed on March 19, 2025 and the next one was due no later than May 19, 2025; however, it was not completed May 21, 2025.
Client #5 was admitted on admitted on July 30, 2024 and discharged on July 8, 2025. A case consultation was completed on July 29, 2024 and the next one was due no later than September 29, 2024; however, it was not completed until December 17, 2024.
Client #6 was admitted on February 26, 2025 and was discharged on May 6, 2025. A case consultation was completed on February 26, 2025 and the next one was due no later than April 28, 2025; however, it was not completed until May 6, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 25, 2024 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.
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