INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection EEEB6701 Rainey's Lighthouse was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection, and a plan of correction is required.
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Plan of Correction
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§ 717.18(c)(1) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of staff records, the facility failed to provide documentation for all staff persons and volunteers to complete Cardiopulmonary resuscitation (CPR) certification training using a department approved curriculum.
Staff #1 was hired as the business manager on May 10, 2019, and was still in this position at the time of the inspection. The CPR for this staff has expired.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Business Manager updated our procedures on 5/16/2026 training for the owner/business manager and house manager. Business manager will complete Cardiopulmonary Resuscitation (CPR) certification training within the timeframe allotted. The house manager does have current CPR certification. Business manager will ensure all new hires complete these trainings with the timeframe allotted. |
§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff records, the facility failed to provide documentation of all staff persons and volunteers to complete HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum within 90 days of hire.
Staff #1 was hired as the business manager on May 10, 2019, and was still in this position at the time of the inspection. There was no documentation of HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum completed.
Staff #2 was hired as the house manager on April 20, 2023, and was still in this position at the time of the inspection. There was no documentation of tuberculosis and sexually transmitted diseases training using a department approved curriculum completed.
These findings were reviewed with the recovery house staff during the licensing process.
This is a repeat citation from the June 3, 2025, annual licensing inspection.
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Plan of Correction
The Business Manager updated our procedures on 5/16/26 to include documentation of HIV/AIDS, tuberculosis and sexually transmitted diseases training for the owner/business manager and house manager. Business manager will ensure all new hires complete these trainings with the timeframe allotted. |
§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
Based on four of seven records reviewed, the facility failed to complete all records obtained under 717.22 within twenty-four hours of the residents arrival.
Resident # 2 was admitted on August 19, 2025, and was still active at the time of the inspection. Beginning of residency paperwork was not signed by the resident until August 23, 2025.
Resident # 3 was admitted on January 16, 2026, and was still active at the time of the inspection. Beginning of residency paperwork was not signed by the resident until January 22, 2026.
Resident # 4 was admitted on April 16, 2026, and was still active at the time of the inspection. Beginning of residency paperwork was not signed by the resident until April 19, 2025.
Resident # 6 was admitted on July 30, 2025, and discharged August 17, 2025. Beginning of residency paperwork was not signed by the resident until August 1-2, 2025.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Business Manager updated our procedures on 5/16/26 to require house manager to complete new intakes within 24 hours of arrival. This update was reviewed with the house manager. House manager will ensure new intakes are completed within 24 hours of arrival. |
§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The bathroom on the second floor had a water temperature of 130 degrees Fahrenheit.
This is a repeat citation from the June 3, 2025, annual licensing inspection.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
During inspection on 5/15/2026, house owner reduced water temperature on water heater. Therefore, this has been corrected. House manager and residents have been notified that they shall not change the water heater temperature gauge in any way. This policy is also now in the rules handbook given to new residents. House manager will monitor water heater temperature gauge to ensure proper water temperature. |