INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2025, 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 to not 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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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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to physical assault or sexual assault by staff or a client.
The facility policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Unusual Incidents:
The CEO will specifically update the policies and procedures for responding to physical assault or sexual assault by staff or client.
This will be completed by the CEO by 11/1/2025. |
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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to selling or use of illicit drugs on the premises.
The facility policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from the September 6, 2024, and September 11, 2023 licensing inspections.
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Plan of Correction
Unusual Incidents:
The policies and procedures will be specifically updated related to how the facility will respond to the selling or use of illicit drugs on the premises.
The CEO will be responsible for this and will be completed by 11/01/2025 |
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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to 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 policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Unusual Incidents:
The policies and procedures will specifically be updated related to procedures for responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances.
The CEO will be responsible for this and will be implemented by 11/1/2025. |
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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
The facility policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Unusual Incidents:
The policies and procedures will be specifically updated on responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrences which closes the facility for more than one day.
The CEO will be responsible for this and this will be implemented by 11/1/2025. |
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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to theft, burglary, break-in or similar incident at the facility.
The facility policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from the September 6, 2024, and September 11, 2023 licensing inspections.
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Plan of Correction
Unusual Incidents:
The policies and procedures will be specifically updated for responding to theft, burglary, breaking or similar incident at the facility.
The CEO will be responsible for this, and this will be implemented by 11/01/2025. |
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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to an event at the facility requiring the presence of police, fire or ambulance personnel.
The facility policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Unusual Incidents:
The policies and procedures will be specifically updated related to responding to an event at the facility requiring the presences of police, fire or ambulance personnel.
The CEO will be responsible for this. This will be implemented by 11/01/2025. |
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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to a fire or structural damage to the facility.
The facility policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Unusual Incidents:
The policies and procedures will be specifically updated for responding to a fire or structural damage to the facility.
The CEO will be responsible for this. This will be implemented by 11/01/2025. |
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 and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures for responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
The facility policy did not identify the unusual incidents they will respond to. The facility listed only numerical numbers one through twelve and did not list unusual incidents, the regulations require eight unusual incidents have policies and procedures for how the facility will respond and five specific unusual incidents that need reported to the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Unusual Incidents:
The policies and procedures will be specifically updated related to the outbreak of a contagious disease requiring Centers of Disease Control notification
The CEO will be responsible for this. This will be implemented by 11/01/2025. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to develop and implement policies and procedures for responding to theft, burglary, break-in or similar incident at the facility was submitted and approved by the Department for the September 6, 2024, and September 11, 2023 annual licensing inspections. Development and implementation of policies and procedures for responding to theft, burglary, break-in or similar incident at the facility was again found to be a deficiency in the Aug 28, 2025, licensing inspection.
A plan of correction to develop and implement policies and procedures for responding to selling or use of illicit drugs on the premises was submitted and approved by the Department for the September 6, 2024, and September 11, 2023 annual licensing inspections. Development and implementation of policies and procedures for responding to selling or use of illicit drugs on the premises was again found to be a deficiency in the Aug 28, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A plan of correction will be completed and added to the policies and procedures. This will specifically address unusual incidents - responding to theft, burglary, break-ins or similar incidents, as well as responding to selling of illicit drugs on the premises. This will specifically address how these incidents will be addressed.
The CEO will develop the procedures on the above, and then include them in the policies and procedures manual. It will also be documented and dated as to when this was completed and implemented.
The CEO will monitor plans of correction by implementing a monthly time on the calendar to review the previous deficiencies and ensure all of the identified plans of correction are still being monitored.
This will be implemented by 11/30/2025. |