INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 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 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 policy manual, 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 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 December 31, 2025; however, an annual individual training plan was not documented in the personnel record until July 27, 2026.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
A re-education of training plan timeframes and regulatory requirements that align with the 704.11 (8)(1) requirements will be reviewed with all staff by October 31, 2026 by management. Project Supervisors will send staff growth and development forms no later than 12/1 yearly to the employee. Supervisors will develop training plan with staff and obtain all signatures by 1/30 of that training year. To prevent further misalignment with the regulatory requirement, going forwards front office staff at each location 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. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of seven records reviewed.
Client #6 was admitted on May 21, 2026, and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information form to a medical provider signed by the client on May 21, 2026, that did not have a purpose identified for disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will receive a re-education on release of information by Supervisor no later than 9/30/2026. Starting 9/30/26 staff will turn all release of information documents to the Supervisor to check for accuracy. Supervisor will then work with clinician if any releases are in need of correction. Effective immediately front office staff will also check releases prior to uploading them into record for accuracy and return to Supervisor for follow up should any releases need attention to align with regulatory requirements and prevent future misalignment with the regulatory requirement. Client #6 was discharged on 10/15/2026 and a new release of information was not obtained prior to discharge. No further communication happened with that medical provider. |
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 the review of client records, the facility failed to document an aftercare plan prior to discharge, per the facility ' s policy and procedures manual in one out three applicable records reviewed.
Client # 4 was admitted on June 25, 2026, and discharged on August 5, 2026. There was no documentation that an aftercare plan was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor will develop and review with staff a discharge process workflow to ensure all documentation required for planned discharge is completed within necessary timeframes and, that align with the 709.93 (a)(9) regulatory requirements by 9/30/2026. To prevent this misalignment from continuing in the future, this workflow will be reviewed monthly by program supervisor with individual staff to ensure necessary aftercare plans are completed to align with the regulatory requirements now and in the future. |