INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection with the client record review completed on August 4, 2026, and the physical plant inspection completed on August 6, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Twin Lakes Center, Inc. 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records and the project's policies and procedures, the project failed to document a written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor within thirty days of hire and yearly in December or January thereafter, per facility policy, in one out of three personnel records reviewed. Employee #1 was hired as a project director on April 22, 2024, and was to have an annual individual training plan documented by January 31, 2025; however, an annual individual training plan was not documented in the personnel record until July 27, 2026.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A re-education of training plan timeframes will be reviewed with all staff by October 31, 2026 to ensure this deficiency does not reoccur and aligns with the regulatory requirement moving forward. Project Supervisors will send staff growth and development forms no later than 12/1 yearly. Supervisors will develop training plan with staff and obtain all signatures by 1/30 of that training year. Front office staff will check training plans for completion prior to deadline of 1/30 and follow up with supervisor if any are in need of development prior to 1/30 of that training year. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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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 the death or serious injury of a client due to trauma, suicide, medication error or unusual circumstances.Project staff were notified of a client death on August 19, 202; however, an unusual incident report was never submitted to the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will receive an education on the updated incident report workflow by 9/30/26. Staff will report all unusual incidents to supervisor within 24 hours of incident. Supervisors will follow up to review that incidents have been submitted online within 3 business days to DDAP. Staff reported the unusual incident on 8/25/2026 |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include an aftercare plan entered prior to discharge, per the facility's policy, in two of two applicable records reviewed.Client #4 was admitted on March 10, 2026, and was discharged on July 8, 2026. Per the facility's policy, the client's aftercare plan was to be documented prior to discharge; however, an aftercare plan was not documented in the client record at the time of the inspection.Client #6 was admitted on January 13, 2026, and was discharged on April 21, 2026. Per the facility's policy, the client's aftercare plan was to be documented prior to discharge; however, an aftercare plan was not documented in the client record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately supervisor will develop and review with staff a discharge process workflow to ensure all documentation required for discharge is completed by necessary timeframes. This workflow will be put in place immediately to ensure that this deficiency does not reoccur. It will be reviewed with staff will occur no later than 9/30/2026. Effective 8/27/2026 supervisor will conduct monthly random chart audits to ensure that an aftercare plan has been completed in the patients record. Three charts per month per staff will be reviewed and discussed during staff supervision with the results of the chart audit. |