INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-6, 2025 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff records, the facility failed to ensure that staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in five of seven applicable records.
Staff #8 was hired to the position of Maintenance on October 25, 2021 and was still in the position at the time of review. The TB/STD training was due to be completed within the first two years of employment, by October 25, 2023. Staff #8 had not completed TB/STD training as of the time of review.
Staff #9 was hired to the position of Maintenance on April 4, 2022 and was still in the position at the time of review. The TB/STD training was due to be completed within the first two years of employment, by April 4, 2024. Staff #9 had not completed TB/STD training as of the time of review.
Staff #10 was hired to the position of Maintenance on October 21, 2019 and was still in the position at the time of review. The TB/STD training was due to be completed within the first two years of employment, by October 21, 2021. Staff #10 had not completed TB/STD training as of the time of review.
Staff #11 was hired to the position of Maintenance on December 14, 2020 and was still in the position at the time of review. The TB/STD training was due to be completed within the first two years of employment, by December 14, 2022. Staff #11 had not completed TB/STD training as of the time of review.
Staff #12 was hired to the position of Housekeeping on July 24, 2023 and was still in the position at the time of review. The TB/STD training was due to be completed within the first two years of employment, by July 24, 2025. Staff #12 had not completed TB/STD training as of the time of review
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Twin Lakes Compliance will pull training materials and curriculum from DDAP website and provide to Twin Lakes Supervisors by 8/31/2025.
Twin Lakes Supervisors will develop a training that will be administered to all current employees that are past due on training by 11/15/25
Supervisors will add onsite TB/STD training to existing "new hire checklist" "training" portion for all new hires moving forward by 11/1/25. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan included the type and frequency of treatment and rehabilitation services in three of six applicable records.
Client #8 was admitted to the inpatient level of care on July 25, 2025 and was active at the time of review. Client #8 ' s comprehensive treatment plan, dated July 28, 2025, did not include the type and frequency of treatment.
Client #9 was admitted to the inpatient level of care on July 17, 2025 and was active at the time of review. Client #9 ' s comprehensive treatment plan, dated July 18, 2025, did not include the type and frequency of treatment.
Client #13 was admitted to the inpatient level of care on April 24, 2025 and was discharged May 20, 2025. Client #13 ' s comprehensive treatment plan, dated April 27, 2025, did not include the type and frequency of treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/11/2025, Twin Lakes Supervisors will re-educate clinical staff during meeting on regulatory requirement to include "type and frequency of treatment" in all treatment plans developed. Signature page will be collected for all staff in the meeting. Any staff not in attendance at the meeting, will review the requirements with their supervisor and sign off on acknowledgement/agreement.
Beginning 10/01/2025, supervisors will be reviewing treatment plans to ensure they have "type and frequency of treatment" during monthly chart audits. Results of chart audits will be shared with clinical staff during supervision. Any treatment plans missing "type and frequency" will be updated during patient's next session. |