INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 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 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 will be reviewed with all staff by October 31, 2026 by program supervisor. 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 needed signatures by 1/30 of that training year to prevent the reoccurrence of this violation. Front office staff will check training plans for completion prior to deadline of 1/30 and also follow up with supervisor if any are in need of development prior to 1/30 of that training year. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of client records, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in one out of one applicable record reviewed.
Client #7 was admitted to the detoxification level of care on May 11, 2026, and left against medical advice on May 14, 2026. There was no documentation that the emergency contact was notified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
TL Residential Supervisor and TL Nurse Manager will develop Discharge Notification Documentation Workflow that will list all regulatory requirements of coordination of client treatment by 10/15/26. Supervisor and Manager will educate staff on this workflow by 10/15/26 to prevent the reoccurrence of this violation in the future. Support Staff will be educated on this workflow and will be responsible to audit all discharge charts to ensure necessary regulatory documentation regarding coordination of client treatment is completed upon discharge from the facility effective 10/15/26 to align with the 709.24 (a)(3) regulation. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection on August 17, 2026, and a review of administrative documents, the facility failed to provide full documentation of quarterly inspections of the storage area that ensures compliance with State and Federal laws and program policy which is to include disinfectants and drugs for eternal use are stored separately from oral and injectable drugs, and drugs requiring special conditions for storage to ensure stability are properly stored.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Twin Lakes Nurse Manager will update Medication Administration Standards policy to encompass the regulatory requirements by 10/2/26. Nurse Manager will develop an inspection checklist for the medication room that will be done at a minimal of quarterly to start no later than 10/2/26. Nurse manager will educate staff of the policy and regulatory requirement as well as the update and checklist completion to be done quarterly by 10/2/26 to prevent the reoccurrence of this violation in the future. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of client records and 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 an event at the facility requiring the presence of police, fire or ambulance personnel.
A client was transported via ambulance to the hospital on February 14, 2026, and there was no documentation that an unusual incident report was filed with the Department.
This finding was 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 10/15/26. 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 ensure the regulatory requirement of 709.34 (c)(4). Supervisor submitted unusual incident that was not reported on 9/3/26. |