INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 4, 2025 through November 5, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Allentown Comprehensive Treatment 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one of seven employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee #6 was hired as a counselor on May 1, 2024 and was still in that position. Employee #6 was due to have the communicable disease training no later than May 1, 2025. There was no documentation that the employee received four hours of TB/STD training at the time of the inspection, and the employee did not receive six hours of HIV/AID training until October 29, 2025.
This is a repeat citation from the October 11, 2024 and October 11, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown Clinical Management team will ensure that each and every staff member completes the required trainings expected during year one (HIV and TB/STD) by scheduling these trainings within the first month of hire during individual supervision with the CS. CD will address trainings during CS's monthly supervision to ensure compliance. Employee #6 MUST complete missing trainings no later than January 31, 2026 and provide CS/CD with certificates of completion. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving a physical or sexual assault by staff or a client.
On December 30, 2024, three clients were reported to have gotten into a physical altercation in the facility parking lot, prompting the involuntary termination of all three clients. A written unusual incident report was not filed with the Department.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
The Clinic Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure for ongoing monitoring of the corrective action plan for an unusual incident. The revision will be completed by December 15, 2025. The Clinic Director will review all policy revisions during the December 3,2025 All Staff Meeting. CD is responsible for entering unusual incidents into the system. CD will report unusual incidents within 24hrs.
CD completed the missing unusual incident reports from 12/30/24 on 12/30/25. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the program failed to transfer the patient file that included admission date, urinalysis reports or summary, exception requests and current status of the patient in one out of one applicable patient record reviewed.
Patient #7 was admitted on February 18, 2020 and transferred to another program on June 4, 2025. There was no documentation that the facility transferred the patient ' s files to the receiving program.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinic Director and Clinical Supervisor will review policy 7.1.14 which addresses the procedures for Transfer Patients. To monitor compliance in this area the Clinic Director or designee will conduct a Quality Record review on all discharge records including patient transfers. During the quality record review of all transferred patients the reviewer will ensure that there is documentation in the patient record that the patients transfer documents including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, and the written consent of the patient was sent to the receiving Program. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the program failed to document the results of annual physical examinations given by the narcotic treatment program, which included an annual reevaluation by the narcotic treatment physician in one out of four applicable records reviewed.
Patient #7 was admitted on February 18, 2020 and transferred to another program on June 4, 2025. The last annual physical exam documented in the patient record was for a physical exam that occurred on February 12, 2024.
This is a repeat citation from the October 11, 2024 annual licensing renewal inspection.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Nursing Supervisor will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians. CTC director will also monitor compliance weekly and address non-compliance with the Physician as needed. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the program failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in one of four applicable patient records reviewed.
Patient #7 was admitted on February 18, 2020 and transferred to another program on June 4, 2025. The last annual evaluation documented in the patient record was on February 22, 2024.
This is a repeat citation from the October 11, 2024, October 11, 2023, October 27, 2022 and November 2, 2021 annual licensing renewal inspections.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on December 3, 2025 in group supervision, as well as, in weekly individual supervision. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally, the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Progress on this plan will be monitored by the CS monthly via the Quality Record Review Process. Ongoing noncompliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of eight records reviewed.
Client #2 was admitted on November 22, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on January 6, 2025, indicated that the client was to receive 2.5 hours of counseling sessions per month; however, there were no counseling sessions in the month of January 2025, the client was only offered .5 hours of counseling in the months of February 2025, April 2025 and May 2025.
Client #4 was admitted on May 14, 2025 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on August 7, 2025, indicated that the client was to receive five counseling sessions per month; however, the client was only offered two counseling sessions for the month of August and three counseling sessions for the month of September.
Client #6 was admitted on February 11, 2022 and was discharged on August 12, 2025. A comprehensive treatment and rehabilitation plan update, documented in the client record on October 9, 2024, indicated that the client was to receive 2.5 hours of counseling sessions per month; however, there were .5 hours of counseling in the months of January 2025 and February 2025.
This is a repeat citation from the October 11, 2024 and October 11, 2023 annual licensing renewal inspections.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on December 3, 2025. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally, the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing noncompliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 and the project's policy and procedure manual, the project failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary entered within 72 hours of the client's discharge, per the facility's policy, in two out of five applicable records reviewed.
Client #3 was admitted on June 4, 2025 and was discharged on October 8, 2025. The discharge summary was not completed until October 24, 2025.
Client #6 was admitted on February 11, 2022 and was discharged on August 12, 2025. The discharge summary was not completed until September 3, 2025.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services, due dates, and appropriate time frame for documentation with all counselors on December 3, 2025. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally, the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing noncompliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 and administrative information, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for mandatory communicable disease trainings being completed within the regulatory timeframe was submitted and approved by the Department for the October 11, 2023, and October 11, 2024, annual licensing inspections. Staff missing or obtaining the mandatory communicable disease training late, were again found to be a deficiency in the November 4, 2025 through November 5, 2025, licensing inspection.
A plan of correction for failing to ensure that counseling services are provided according to the individual treatment and rehabilitation plan, was submitted and approved by the Department for the October 11, 2023, and October 11, 2024, annual licensing inspections. Providing counseling services according to the individual treatment and rehabilitation plan was again found to be a deficiency in the November 4, 2025 through November 5, 2025, licensing inspection.
A plan of correction for documenting a patient annual evaluation was submitted and approved by the Department for the November 2, 2021, October 27, 2022, October 11, 2023, and October 11, 2024, annual licensing inspections. Completing a patient annual evaluation was again found to be a deficiency in the November 4, 2025 through November 5, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CD and the CS will review the identified item(s) and collaboratively prepare a sustainable corrective measure; all in concert with Licensing regulations and input working to ensure a sustained corrective measure. CS is responsible for staff training requirements. These will be reviewed monthly in individual supervision. CD will review with CS completion of trainings bi-monthly. CS will provide a training on proper documentation in person-centered treatment plans for patient counseling services and on time documentation of Annual Clinical Reviews, no later than December 31, 2025. Ongoing noncompliance will be addressed by the CS or CD individually utilizing the Employee Improvement Plan process. |