INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted May 28, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site investigation, Allentown Comprehensive Treatment Center, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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715.7(a)(1-2) LICENSURE Dispensing or administering staffing
(a) A narcotic treatment program shall be staffed as follows:
(1) If it operates an automated dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
(2) If it operates a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients.
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Observations
The facility failed to have one full-time nurse to administer or dispense a controlled substance for every 200 patients.On March 10, 2026, the patient census was 491 and there was only one nurse working in the dosing area.
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Plan of Correction
Facility has been dealing with a nursing shortage. As of today's date, facility has started a new nurse supervisor, and has made two offers, which have been accepted. It is anticipated that a new full time and part time nurse will start once cleared in two weeks. We have another part time nurse who is returning from a LOA next week and are also currently utilizing nurses from other facilities in the region. It is expected that facility nurses be fully onboarded and trained no later than the 2nd week in July. |
715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
The facility failed to have sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area. On March 10, 2026, 10/84% of patients waited an average of 20.42 minutes, and 6.02% of patients waited an average of 30.18 minutes. A total of 14 out of 83 patients waited over 15 minutes.On May 12, 2026, 7.5% of patients waited 18.72 minutes, 10% of patients waited 30.93 minutes, 26.25% of patients waited 48.72 minutes, and 7.5% of patients waited 91.50 minutes. A total of 35 out of 83 patients waited over 15 minutes.On May 14, 2026, 13.41% of patients waited 20.34 minutes, 9.76% of patients waited 31.53 minutes, 35.37% of patients waited 43.91 minutes, and 26.83% of patients waited 75.10 minutes. A total of 70 out of 82 patients waited over 15 minutes.
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Plan of Correction
Facility is opening 30 minutes earlier in the mornings to allow workers additional time for medicating. A review of takehome schedules was conducted and some patients asked to voluntarily switch days to decrease volume on more highly attended days during the week. Dedicated lines for dosing have also been established to separate out individuals with little to no takehomes and those with extended bottles, so as to move people through faster. As inidicated in previous response, it is expected for average wait times to drop within the 15mins in the next couple of weeks as new staff are onboarded and trained. |