INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2025, 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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? 717.15(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
Based on a review of the house manager personal record, the facility failed to provide documentation of the house manager completing at least 6 hours of training for the 2024 training year.
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 the annual required training provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Business manager updated procedures on 6/3/25 to include that 6 hours of annual training is to be completed by the house manager. Business manager will audit personnel record prior to annual trainings being due to ensure they have been completed. |
§ 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 if HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum was 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 if HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum was completed.
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 6/3/25 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.
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§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on three of five discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident # 4 was admitted on March 13, 2025, and discharged May 20, 2025. There was no documentation of an end to residency in the resident record.
Resident # 7 was admitted on January 16, 2025, and discharged March 4, 2025. There was no documentation of an end to residency in the resident record.
Resident # 8 was admitted on August 26, 2024, and discharged November 18, 2024. There was no documentation of an end to residency in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Business Manager updated procedures on 6/3/25 to provide a notification to end residency to all residents, even those who end residency due to their own choice and not due to removal. Business manager will ensure all emergency contacts are notified within 12 hours of end of residency and document it in the resident's file. |
§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
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Observations
Based two of five discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident # 4 was admitted on March 13, 2025, and discharged May 20, 2025. There was not a notification to the emergency contact provided in the resident record.
Resident # 7 was admitted on January 16, 2025, and discharged March 4, 2025. There was not a notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Business Manager updated procedures on 6/3/25 to document the notification to the emergency contact for all residents who leave the facility, including successful completions. Business manager will ensure all emergency contacts are notified within 12 hours of end of residency and document in the resident's file. |
§ 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 water temperature was read at 139 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
During inspection on 6/3/2025, 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. |