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. 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. To prevent further misalignment with the regulatory requirement, going forwards 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. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on August 6, 2026, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. When tested, the hot water in the front hallway bathroom was 130.9 degrees Fahrenheit.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 8/13/26, Director Compliance & Regulatory submitted a facility exception request to 705.24(3) since Twin Lakes rents this facility. On 8/28/2026 TL manager contacted the building manager to educate him on the regulation that the water temperature cannot exceed 120 degrees at any time. Building manager communicated that he will have regulators added to the building faucets by 9/30/2026 to ensure compliance with the water temperature requirement. Front office staff will check the water temp monthly to ensure water temps remain compliant. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of seven records reviewed.Client # 5 was admitted on May 11, 2026, and was discharged on June 22, 2026. A release of information form for a family member signed by the client on May 11, 2026, did not specify the specific information to be disclosed.The findings were reviewed with project 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 the regulatory requirement and prevent further misalignment. |
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 the review of client records, the project 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 two of seven records reviewed.Client # 1 was admitted on November 11, 2025, and was active at the time of the inspection. A release of information form for a probation agency signed by the client on November 11, 2025, did not specify the purpose of disclosure.Client # 4 was admitted on December 11, 2025, and was discharged on June 24, 2026. A release of information form for a probation agency signed by the client on December 11, 2025, did not specify the purpose of disclosure.The findings were reviewed with project 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. |