| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1 had a signed statement acknowledging receipt of individual rights on 4/19/16 and then again on 12/13/17. | 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. | Supervisors are responsible for recording annual dates for each of their individuals. PathWays Residential Program will be creating a running chart to capture everyone¿s annual dates. The assistant director will oversee this chart. Additionally, starting May 2018, PathWays Residential Program will be implementing internal quarterly audits to ensure compliance. [Immediately, the residential director or designated management staff person shall develop and implement a tracking system to ensure individuals are informed of their rights and signed and dated statements acknowledging receipt of information on rights is kept. At least quarterly, a designated management staff person shall audit the tracking system and a 5% sample of statement to ensure all individuals are informed of individual rights, timely and signed and dated statements are kept. Documentation of audits shall be kept. (AS 4/6/18)] |
12/13/2017
| Implemented |
| 6400.112(c) | The written fire drill records for the monthly fire drills held in March, June and September 2017 did not include the time of the drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Starting May 2018, PathWays Residential Program will be using an updated fire drill record. Supervisors will still follow the already established procedure. Once the fire drill is completed, the supervisor faxes a copy to the office where it is stored in a master fire drill binder. The binder is reviewed monthly by the assistant director. [Within 30 days of receipt of the plan of correction, a designated management staff person shall educate all staff persons responsible for conducting and documenting fire drills of the requirements as per 6400.112(a)-(I). Documentation of the trainings shall be kept. Upon completion of fire drills, a designated management staff person shall audit the fire drill records to ensure all fire drills are conducted and documented as required. Documentation of the audits shall be kept. (AS 4/6/18)] |
05/01/2018
| Implemented |
| 6400.144 | On 3/20/18, the blister package of APAP 325 mg 2 tabs every 4 hours as needed for pain, prescribed 6/13/16 for Individual #1, had an expiration date of 6/2017, remained in Individual #1's medication box. The blister package of Mucinex 600 mg 1 tab twice daily as needed for cough and congestion, prescribed 10/11/16 for Individual #1, had an expiration date of 10/2017, remained in Individual #1's medication box. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| On 3/20/18, the medication was removed from the PRN box and a new one was added. PathWays Residential Program requires staff to check all medications when administering daily medications. Additionally, supervisors perform monthly house checks. Starting May 2018, PathWays Residential Program will be implementing internal quarterly audits to ensure compliance. [With 30 days of receipt of the plan of correction, a designated staff person certified to complete medication administration training shall educate all staff persons responsible for administering and disposing of medications of the procedures for checking and disposing of medications on the procedures to ensure expired medications are not available. Documentation of trainings shall be kept. Upon completion of training and continuing at least monthly, designated staff person(s) shall audit all individuals' medications, medication storage areas, doctors' orders and medication administration records to ensure all individuals' are administered medications as prescribed and medications are current and not expired. Documentation of audits shall be kept. (AS 4/6/18)] |
03/20/2018
| Implemented |
| 6400.181(d) | Individual #1's assessment, completed 2/13/18, was not signed by a program specialist. | The program specialist shall sign and date the assessment. | The program specialist will complete and sign all assessments. Once an assessment is fully completed and signed by the PS, the assistant director and/or director will review. After the assessment has been reviewed by the RAD/RPD, it will be presented to the individual. [Immediately, the program specialist shall sign and date Individual #1's assessment, completed 2/13/18. Within 30 days of receipt of the plan of correction, the program specialist and a designated management staff person shall review all individuals' assessments to ensure the program specialist has signed and dated all individuals' current assessments. Within 60 days of receipt of the plan of correction, aforementioned review process by the director(s) shall be completed. Documentation of aforementioned reviews by the director(s) shall be kept. (AS 4/6/18)] |
04/04/2018
| Implemented |
| 6400.186(a) | The program specialist completed an ISP review with Individual #1 on 9/18/17 and then again on 3/5/18. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Pathways Residential Program has the Program Specialist complete all quarterly reviews with the data supplied during the specified time frame. The PS will check the information. Then, the Residential Director will conduct a second check of the information and then sign the review. Once this takes place, the quarterly review will be presented to the individual.[Immediately, the residential director shall develop and implement a tracking system to ensure the program specialist and individual review the ISP reviews, timely. Within 30 days of receipt of the plan of correction, designated management staff person shall educate the program specialist(s) on the aforementioned procedures to ensure timely completion of reviews of the ISP reviews. Documentation of trainings shall be kept. (AS 4/6/18)] |
04/04/2018
| Implemented |