INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Another Way, 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 applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of five staff records.
Staff #3 was hired as a counselor on April 14, 2025 and was still in this position at the time of the inspection. HIV/AIDS training was to be completed no later than April 14, 2026; however, this was not completed until May 12, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #3 was informed several times that he needed to have his HIV/AIDS training to be completed by April 14, 2026. He was given an employee memo on November 5, 2025 informing him of the trainings that needed to be completed by April 14, 2026. Then given an employee write up regarding his failure to complete these training on 4/23/26. He completed HIV/AIDS training on May 12, 2026. The fiscal officer will provide new hires with a timetable for all required trainings to be completed within the DDAP required time frames. The fiscal Officer will continue to monitor trainings on a quarterly basis. We are in full compliance as of 09/30/26 |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in two of six records.
Client #1 was admitted on February 11, 2026 and was still active at the time of the inspection.
HCTZ was prescribed for one tablet to be taken once a day. The June 2026 MAR documented that this medication would be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on June 26, 2026.A Compound with Pads was prescribed for one patch to be applied topically once a day. The July 2026 MAR documented that this medication would be applied at 8:00am. After a review of the facility medication administration records, the client did not acknowledge receipt of the medication on July 7, 2026.Mirtazapine was prescribed for one tablet to be taken at bedtime. The July 2026 MAR documented that this medication would be given at 10:00pm. After a review of the facility medication administration records, there was missing documentation that the medication was given on July 12, 2026; July 23, 2026; and July 30, 2026.Prazosin was prescribed for one tablet to be taken at bedtime. The July 2026 MAR documented that this medication would be given at 10:00pm. After a review of the facility medication administration records, there was missing documentation that the medication was given on July 23, 2026; July 24, 2026; and July 30, 2026.
Client #6 was admitted on December 23, 2025 and was discharged on June 19, 2026.
Famotidine was prescribed for one tablet to be taken twice a day. The April 2026 MAR documented that this medication would be taken at 8:00am and 10:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on April 4, 2026. Additionally, there was no documentation of this medication being given at 10:00pm on April 10, 2026.Hydroxyzine was prescribed for one capsule to be taken at bedtime. The April 2026 MAR documented that this medication would be taken at 10:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on April 10, 2026.Lamotrigine was prescribed for one tablet to be taken once a day for thirty days. The April 2026 MAR documented that this medication would be given at 8:00am. After a review of the facility medication administration records, there was missing documentation that the medication was given on April 4, 2026.Omeprazole was prescribed for one capsule to be taken at bedtime. The April 2026 MAR documented that this medication would be taken at 10:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on April 10, 2026.Sertraline was prescribed for one tablet to be taken at bedtime. The April 2026 MAR documented that this medication would be taken at 10:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on April 10, 2026.Trazodone was prescribed for one tablet to be taken at bedtime. The April 2026 MAR documented that this medication would be taken at 10:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on April 10, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In two of the charts the behavioral techs did not document properly on the MAR sheets. The senior behavioral tech had a meeting with all techs that give medications on August 26, 2026 and reviewed policies and procedures for medication management and proper MAR Documentation. The importance of marking R-Refused, A- Absent and if clients received medications and then marking with their initials and placing check mark on the date box. Plan of correction is that the assigned tech will monitor the medication logs weekly and the senior behavioral tech will monitor medication logs monthly when they are filed in the client's chart. Then the medication logs will be reviewed again during quality Assurance. After the client completes treatment the MAR sheets will be monitored again. The senior behavioral tech will be responsible for reviewing each MAR sheet for accuracy and compliance. We will be in full compliance on 9/30/26 |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in seven of seven records. The facility's policy and procedure manual indicated an initial comprehensive treatment and rehabilitation plan be completed within seven days of admission into the program.
Client #1 was admitted on February 11, 2026 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan was developed on February 18, 2026; however, it did not include documentation of the plan being developed with the client until February 23, 2026.
Client #2 was admitted on March 10, 2026 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan was developed on March 18, 2026; however, it did not include documentation of the plan being developed with the client until March 24, 2026.
Client #3 was admitted on March 26, 2026 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan was developed on March 31, 2026; however, it did not include documentation of the plan being developed with the client until April 7, 2026.
Client #4 was admitted on September 19, 2025 and was discharged on February 10, 2026.
The comprehensive treatment and rehabilitation plan was developed on September 22, 2025; however, it did not include documentation of the plan being developed with the client until September 29, 2025.
Client #5 was admitted on March 17, 2026 and was discharged on May 26, 2026.
The comprehensive treatment and rehabilitation plan was developed on March 25, 2026; however, it did not include documentation of the plan being developed with the client until March 31, 2026.
Client #6 was admitted on December 23, 2025 and was discharged on June 19, 2026.
The comprehensive treatment and rehabilitation plan was developed on December 30, 2025; however, it did not include documentation of the plan being developed with the client until January 7, 2026.
Client #7 was admitted on September 2, 2025 and was discharged on March 2, 2026.
The comprehensive treatment and rehabilitation plan was developed on September 4, 2025; however, it did not include documentation of the plan being developed with the client until September 15, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical team starts treatment planning with clients at admit. Clinical Team was using the date on top of the master treatment plan as the date they typed the master treatment plan and then reviewed it and signed the bottom with the client. They documented it in an individual note on that day. Meeting was held with clinical team and reviewed the policy for treatment plan dates on 8/21/26. The clinical team will make the treatment plan dates uniform with the date they develop it with client to ensure documentation in individual note of reviewing the Master Treatment Plan. The facility director will monitor that we will remain in compliance. We will be in compliance on 9/30/26 |