Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236467 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed 7/14/2023, was not conducted within 3 to 6 months prior to the expiration date of the agency's certificate of compliance.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The new Residential Director and the Clinical Manager will receive training on the self-assessment, including when they're required to be completed, by the SVP of Program Operations by 1/5/24. A new self-assessment will be completed for all homes by the Residential Director and/or Clinical Team by 1/31/24. 01/31/2024 Implemented
6400.15(c)The self-assessment completed 7/14/2023 did not include a written summary of corrections made for the following regulations: 6400.20b and 6400.67a.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The new Residential Director and the Clinical Manager will receive training on the self-assessment, including writing a summary of corrections, by the SVP of Program Operations by 1/5/24. A new self-assessment will be completed for all homes by the Residential Director and/or Clinical Team by 1/31/24. 01/31/2024 Implemented
SIN-00221690 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(c)(3)Program Specialist #1, date of hire 12/13/22, does not have the work experience required for the program specialist position.A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism.A background collection and analysis of the Program Specialist #1 (PS) qualifications and process for hire was completed. All other Program Specialists/Clinical Specialists qualifications were reviewed, along with validating qualifications identified in the Job Descriptions with the regulations (and waiver amendments). The PS #1 qualifications indicated 3.5 years of work experience working directly with individuals with an intellectual disability or autism. The PS #1 will perform work in another direct capacity until July 13, 2023, when reinstatement to the Program Specialist position will occur. The ATF Assistant Director (bachelor degree and 2 years experience) has assumed Program Specialist responsibilities until reinstatement. 04/25/2023 Implemented
SIN-00172274 Renewal 03/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment, dated 8/21/19, was not completed in the following areas: General Requirements, Staffing, Staff Health, Provider Services, Day Services, Restrictive Procedures. These sections of the self-assessment were blank.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Currently, we complete all self assessments during the month of August. We will continue to utilize the same schedule. Moving forward, we will conduct the self-assessments in two phases. Phase one will be completed by the house coordinators between the 1st and 15th of August. They will complete the following areas: Individual Records, Restrictive Procedures, Day Services, Individual Rights, Physical Site, Fire Safety, Individual Health, Medications, Nutrition, Assessments, and Plan Development. Phase two will be completed by the house managers between the 15th and 30th of August. They will ensure that phase one was completed properly and personally complete the following areas: General Requirements, Staffing, Staff Health, Home Services, Semi-independent living, Respite Care, Emergency Placement, and 9 or more individuals.[Additional POC information provided on 3/26/2020 by Residential Program Director: The Managers will turn in all their self assessments to the director by the 31st of August. The Director will ensure that all self assessments have been turned in timely and fully completed. On 3/10/20 a meeting/training was conducted for all the coordinators and managers to review the RCG and our new self assessment procedure. [Documentation of the audits and trainings shall be kept.](DPOC by AES,HSLS on 3/30/20)] 03/06/2020 Implemented
SIN-00110817 Renewal 03/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment was completed on 12-2-16. The agency's certificate of compliance expired on 12-25-16.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Pathways of Southwestern Pennsylvania, Inc.¿s. current Certificate of Compliance expires on 12/25/2017. This makes the identified time period for Self Assessments to be completed 06/25/2017 ¿ 09/25/2017. This time period will be added to our Inspection Calendar on our internal website. The identified time period will also be added to the Outlook Calendar for each member of the Residential Management Team, this includes the Residential Program Director, Assistant Director and Program Training & Compliance Specialist and the Outlook Calendar for all Residential Program Supervisors. The identified time period was added to all above listed calendars on 04/04/2017. [Prior to 3 months of the expiration date of the current certificate of compliance the director shall review the completed self-assessments to ensure timely completion. (AS 4/24/17)] 04/13/2017 Implemented
6400.186(d)The program specialist provided the ISP review documentation ending on 8-11-16 and 11-11-16 for Individual #1 to the plan team members on 2-1-17. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. As of March 1, 2017 the delay between completing and sending quarterly reviews to all team members has been corrected. Pathways Residential Program has adopted the internal policy to complete the quarterly review, including all required signatures, within a 14 day period. By regulation, the completed quarterly review must be sent to all team members within 30 days of completion. This will be tracked through the use of ¿Rolling Program Specialist Chart¿, currently under development. The ¿Rolling PS Chart¿ will include each client, each quarterly review period, the date that each quarterly review was completed and the date that each quarterly review was sent to all team members. The ¿Rolling PS Chart¿ will be updated by the Program Specialist as each step of the process is completed and located in a computer drive accessible by the Program Director for periodic review. [At least quarterly for 1 year the program director shall review a 25% sample of documentation showing that the program specialist provided all individuals' ISP reviews to plan team members within 30 days after the ISP review. (AS 4/24/17)] 04/13/2017 Implemented
SIN-00075638 Renewal 02/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)Individual #1 did not sign the three month ISP reviews ending on 9/15/14 and 12/15/14.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. All program specialists were retrained on Maintaining Quarterly Records w/ Appropriate Signatures on 3/4/15. Copy included for your review. The 3 month reviews in question were re-printed and reviewed with the individual and re-signed. Copies included for your review. Program director has created and implemented a PS Drive for the storage and record keeping of all program specialist documents and signed copies will be scanned into the drive. Residential managers, program specialists and supervisors are responsible for regular internal chart reviews with corrections being completed within 48 hours. Copy included for your review. 03/04/2015 Implemented
SIN-00053754 Renewal 01/21/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The Individual rights statement signed by the individuals of the home did not include the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary.(b) Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Individual rights statements were updated immediately and copy was provided to licensing inspectors. Copies were given to residential program specialist for four individuals who reside at Ewing house to have re-signed. This form will be used for all new admissions. [Per conversation with provider on 3/18/14, Program Specialists will educate all individuals of the program and provide a copy of the updated rights to all individuals of the program by 4/15/14. Documentation shall be kept in the individual's record. (CHG 3/18/14)] 02/24/2014 Implemented
6400.106The two most recent furnace inspections were completed on 5/1/13 and 11/21/11.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnace inspections will be completed within one year from 5/1/13 and will be placed on calendars as a reminder to schedule approximately one month prior to actual due date each year 02/24/2014 Implemented
SIN-00203874 Renewal 04/21/2022 Compliant - Finalized
SIN-00091066 Renewal 03/03/2016 Compliant - Finalized
SIN-00042688 Renewal 09/17/2012 Compliant - Finalized