D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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ANOTHER WAY, INC.
708 NELSON ROAD
FARMINGTON, PA 15437

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Survey conducted on 08/18/2021

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on August 18, 2021 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:	Plan of Correction
709.34 (c) (4) LICENSURE Reporting of unusual incidents § 709.34. Reporting of unusual incidents. (c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (4) Event at the facility requiring the presence of police, fire or ambulance personnel.
Observations Based on a review of unusual incident reports and an interview with facility staff, the project failed to document written unusual incident reports were filed with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire, or ambulance personnel. Unusual incident reports were reviewed on August 18, 2021. Two unusual incidents occurred at the facility requiring the presence of ambulance personnel on June 11, 2021 and September 24, 2020. The facility failed to provide documentation of these unusual incidents being reported to the Department within 3 business days. The findings were reviewed with facility staff during the licensing process.	Plan of Correction Upon site inspection we provided the original unusual incident reports. Two of which were not found in the DDAP system. At the time of the inspection we were unable to provide receipts that these two incident reports were sent. In order to maintain compliance with unusual incident reports the following plan of correction will immediately take place. In the case of a unusual incident any Another Way Staff member will complete a DDAP unusual incident report and contact the facility director or senior behavioral tech. Within three business days of the occurrence of the incident. The facility director or senior behavioral tech will submit the report electronically to the Electronic Reporting system on DDAP.PA.GOV. From that site we will print the report and staple it to the original report and file it in the unusual incident binder located in the tech office. In the occurrence that report was unable to be electronically submitted the report will be faxed to DDAP and the fax receipt printed and stapled to original report. If report is sent via email a copy of the message from the outgoing folder will be printed and stapled to the original report. Currently we are in Full Compliance. The facility director will continue to ensure compliance by monitoring the incident report binder.