INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lighthouse Counseling Associates 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for the individual ' s primary position, which is a counselor in one out of one record reviewed.
Employee #1 was hired as the project director and counselor on September 1, 1992, and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from November 1, 2024 through October 31, 2025. Employee # 1's record only document 13 clock hours of annual training completed for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO is responsible for completing 25 clock hours of annual training for her primary position.
The CEO will complete 25 hours of training moving forward. Training year is November 1,2025 to November 30, 2026.
This will be completed within the next month.
The CEO will complete 25 clock hours per year of annual training for her position. The CEO will keep a log of all trainings scheduled and attended within the adequate time frame, and will review this consistently to make sure she is up to date with training hours. Certificates of attendance will then be kept in personnel file.
This will be completed by 11/1/2026. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on August 11, 2026, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The fire extinguisher located in the main corridor of the facility was last inspected in March 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguisher will be inspected yearly. The CEO will contact the fire extinguisher company to have this done. This will be done within the next month.
The fire extinguisher will be inspected yearly. The CEO will contact the fire extinguisher company to schedule for them to come out and do the inspection. A log will be kept and checked consistently to make sure this is completed on a yearly basis. The CEO will be responsible for carrying this out.
This will be completed by 11/1/26. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of one record reviewed.
Client #1 was admitted on June 26, 2024, and was still active at the time of inspection. The release of information for the funding source expired on December 26, 2024. There was no documentation that the facility obtained a current informed and voluntary consent for the funding source. The facility confirmed that the funding source was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will obtain a voluntary consent from the client whose chart was reviewed for the disclosure of information contained in their record. The release will be to continue to bill the clients insurance for services rendered. This will be completed within the next month.
The CEO will obtain a signed voluntary consent from the client whose chart was reviewed for the disclosure of information contained in their record. The release will be to continue to bill the clients insurance for services rendered. This will be monitored on a consistent basis to make sure this is kept up to date.
This will be completed by 11/1/26 |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to a physical assault or sexual assault by staff or a client.
The facility ' s policy failed to document procedures for how the facility will respond to a physical assault or sexual assault by staff or a client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will document, in depth, on how the facility will respond to a physical and/or sexual assault by staff or client. This will be documented in the policies and procedures manual. This will be completed within the next month.
The CEO will document, in depth, on how the facility will respond to a physical and/or sexual assault by staff or client. This will be documented in the policies and procedures manual. This will continue to be monitored on a consistent basis and if any updates are needed they will be incorporated.
This will be completed by 11/1/26. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to selling or use of illicit drugs on the premises.
The facility ' s policy failed to document procedures for how the facility will respond to selling or use of illicit drugs on the premises.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will document, in depth, how the facility will respond to selling or use of illicit drugs on the premises. This will be documented in the policies and procedures manual. This will be completed within the next month.
The CEO will document, in depth, how the facility will respond to selling or use of illicit drugs on the premises. This will be documented in the policies and procedures manual. This will be monitored on a consistent basis. If updates are needed to this policy it will be done in a timely manner.
This will be completed by 11/1/26. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
The facility ' s policy failed to document procedures for how the facility will respond to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will document, in depth, procedures for how the facility will respond to a death or serious injury due to trauma, suicide, or unusual circumstances when know by the facility. This will be documented within the policies and procedures manual. This will be completed within the next month.
The CEO will document, in depth, procedures for how the facility will respond to a death or serious injurty due to trauma, suicide, or unusual circumstances when known by the facility. This will be documented within the policies and procedures manual. This will be reviewed on a consistent basis, and if updates are needed they will be implemented in a timely manner.
This will be completed by 11/1/26. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to a significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day.
The facility ' s policy failed to document procedures for how the facility will respond to a significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO, will document, in depth, how the facility will respond to a significant disruption of services due to a disaster, such as a fire, storm, flood, or other occurrence which closes the facility for more than one day. This will be documented within the policies and procedures manual. This will be completed within the next month.
The CEO will document, in depth how the facility will respond to a significant disruption of services due to a disaster, such as a fire, storm, flood, or other occurrence which closes the facility for more than one day. This will be documented within the policies and procedures manual. This will be reviewed on a consistent basis and if updates are needed they will be implemented within a timely manner..
This will be completed by 11/1/26. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to a theft, burglary, break-in or similar incident at the facility.
The facility ' s policy failed to document procedures for how the facility will respond to a significant disruption of services due to a theft, burglary, break-in or similar incident at the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO, will document, in depth, how the facility will respond to a significant disruption of services due to theft, burglary, break-in or similar incident of the facility. This will be included within the policies and procedures manual. This will be completed within the next month.
The CEO will document, in depth, how the facility will respond to a significant disruption of services due to theft, burglary, break-in, or similar incident of the facility. This will be included within the policies and procedures manual. This will be reviewed on a consistent basis and if updates are needed, will be implemented in a timely manner.
This will be completed by 11/1/26 |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to an event at the facility requiring the presence of police, fire or ambulance personnel.
The facility ' s policy failed to document procedures for how the facility will respond to a significant disruption of services due to an event at the facility requiring the presence of police, fire or ambulance personnel.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO, will document, in depth, how the facility will respond to a significant disruption of services due to an event at the facility requiring the presence of police, fire or ambulance personnel. This will be documented within the policies and procedures manual. This will be completed within the next month.
The CEO, will document, in depth, how the facility will respond to a significant disruption of services due to an event at the facility requiring the presence of police, fire or ambulance personnel. This will be documented within the policies and procedures manual.. This will be reviewed on a consistent basis and if updates are needed will be implemented within a timely manner.
This will be completed by 11/1/26. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to a fire or structural damage to the facility.
The facility ' s policy failed to document procedures for how the facility will respond to a significant disruption of services due to a fire or structural damage to the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will document, in depth, how the facility will respond to a significant disruption of services due to a fire or structural damage to the facility. This will be documented within the policies and procedures manual. This will be completed within the next month.
The CEO will document, in depth, how the facility will respond to a significant disruption of services due to a fire or structural damage to the facility. This will be documented within the policies and procedures manual. This will be reviewed on a consistent basis and if updates are needed will be implemented within a timely manner.
This will be completed by 11/1/26. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of administrative documents, the facility failed to develop and implement unusual incident policies and procedures to respond to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
The facility ' s policy failed to document procedures for how the facility will respond to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO, will document, in depth, how the facility will respond to an outbreak of a contagious disease, requiring Centers for Disease Control notification. This will be documented within the policies and procedures manual. This will be completed within the next month.
The CEO, will document, in depth, how the facility will respond to an outbreak of a contagious disease, requiring Centers for Disease Control notification. This will be documented within the policies and procedures manual. This will be reviewed on a consistent basis and if updates are needed, they will be implemented within a timely manner.
This will be completed by 11/1/26. |