This report is a result of an on-site licensure renewal inspection conducted on December 08, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lakeside NEPA, 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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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in two out of seven client records reviewed.
Client #6 was admitted on February 03, 2025, and discharged on June 02, 2025. A consent form signed and dated May 21, 2025, for an updated funder, did not have documentation that the client was offered a copy of the consent form.
Client #7 was admitted on June 04, 2025, and discharged on November 18, 2025. A consent form signed and dated June 13, 2025, for an updated funder, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.29 (d) Licensure Confidentiality. The facility failed to document that a copy of a client consent for funder was offered to the client, and a copy was maintained in the client record. The CEO and the COO conducted training on December 9, 2025, to inform staff members on the importance of completing the consent forms, checking all boxes, and offering the client a copy of the consent. The staff will complete new releases in place of the old releases starting December 10, 2025, to ensure that the client is offered a copy. All current clients that need a new release will have one by January 31, 2026. The CEO and COO will complete monthly audits of the releases, starting on January 5, 2026, to ensure that the releases are completed correctly and on time. |