Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236470 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed 8/31/2023 did not include regulations 6400.11 to.6400.25d; 6400.42 to 6400.52c6, 6400.151a to 6400.152c, 6400.182a to 6400.207(2) and 6400.231 to 6400.275. They 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. The new Residential Director and the Clinical Manager will receive training on the self-assessment, including completing fully, 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
6400.34(a)Individual #2, date of admission 5/30/2023, was not informed of the individual rights upon admission to the home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The individual rights were rereviewed with the individual on 12/18/23 by the Clinical Specialist and the individual signed off on the form that day. 12/29/2023 Implemented
6400.166(a)(7)Individual #1 is prescribed Humalog Kwik Injection 100/ml, with instructions to "use sliding scale at bedtime, only if he has a snack, use this scale: 251-300=2U, 201-350=3U, >351=4U for Diabetes." During the inspection conducted 12/13/2023, Individual #1's December 2023 medication administration record did not include the amount of medication administered from 12/01/2023 through 12/12/2023 at 8:00pm.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.On 12/13/23, the Community Health Director contacted the pharmacy to add injection site and amount given to the MAR. The additional information was added on 12/18/23. SVP of Program Operations confirmed on 12/26/23, the staff were documenting the necessary information on the new lines. 01/03/2024 Implemented
6400.166(a)(8)Individual #1 is prescribed Humalog Kwik Injection 100/ml, with instructions to "use sliding scale at bedtime, only if he has a snack, use this scale: 251-300=2U, 201-350=3U, >351=4U for Diabetes." During the inspection conducted 12/13/2023, Individual #1's December 2023 medication administration record did not include the route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.On 12/13/23, the Community Health Director contacted the pharmacy to add the route of administration. The additional information was added on 12/18/23. SVP of Program Operations confirmed on 12/26/23, the staff were documenting the necessary information on the new lines. 01/03/2024 Implemented
6400.166(a)(15)Individual #1 is prescribed Glucagon Kit 1mg, with instructions "if blood sugar is lower than 90, offer the individual apple or orange juice. If this does not work or he passes out, inject 1mg once for dose as needed for Hypoglycemia. Open kit, take out small vial and take off tab, take out syringe and squirt into vial once pierced." During the inspection conducted 12/13/2023, Individual #1's December 2023 medication administration record stated Glucagon Kit 1mg, "Inject 1mg once for dose as needed for Hypoglycemia."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable.The Community Health Director contacted the endocrinologist on 12/14/23 for additional instructions. That day, they faxed the order again (which isn't specific) and the ADA definition of hypoglycemia. It was explained that we needed more specific instructions on when to administer the Glucagon. The Residential Director left a message again on 12/29/23 requesting a call back. PathWays is requesting for the endocrinologist's office to review and sign off on (if agreed upon) the instructions the PathWays nurse wrote up. The Community Health Director and Residential will continue following up with the doctor's office until resolved and then the MAR and label can be updated. It was confirmed that all staff working in the home have been trained on the protocol and the protocol is in the home. 01/31/2024 Implemented
SIN-00203876 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #2's 4/08/22 individual plan states the following: all cleaning products are locked away for safety. Individual #2 is aware of warning labels such as Mr. Yuck stickers but may not pay attention to them. They are unable to explain what a substance may be used for or even identify it by its color or use and may mistake a harmful substance for something edible. During the inspection conducted on 4/22/2022, the detached, key-locked garage contained 32 fluid ounce bottle of Backyard Odorless Lighter Fluid and a 6 fluid ounce can of Krylon Glows spray paint. Individual #2 has a key to this garage and is provided access.Poisonous materials shall be kept locked or made inaccessible to individuals. On 4/22/22 the cited poisonous materials were locked in a cabinet in the garage. These materials belonged to another individual who lives in the home. That individual was made aware that when he is finished using these products they need to be locked in the designated cabinet. 04/22/2022 Implemented
6400.81(k)(6)During the inspection conducted on 4/22/2022, Individual #2's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. The mirror was replaced on 4/22/22 minutes after the inspector left. 04/22/2022 Implemented
6400.111(f)During the inspection conducted on 4/22/2022, there was a fire extinguisher identified in the laundry room next to the kitchen that was last inspected in March 2021. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. On 4/27/22 the fire extinguisher was inspected, and a new tag was placed on it. The maintenance director oversees the completion the annual fire extinguisher inspections. 04/27/2022 Implemented
6400.171During the inspection conducted on 4/22/2022, there were two 16 oz. containers of sour cream both with an expiration date of 11/22/2021.Food shall be protected from contamination while being stored, prepared, transported and served. The expired food was immediately discarded on 4/22/22. 04/22/2022 Implemented
6400.163(a)Individual #1's April 2022 Medication Administration Record indicates the following: Vitamin D3 Gummy 2000 IU: Chew 1 gummy by mouth every day for supplement. The label on the medication bottle states to chew 2 gummies daily. No physician's orders existed, showing updated medication administration instructions.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.A new label from the pharmacy was delivered on 4/22/22 and placed on the medication bottle. 04/22/2022 Implemented
6400.166(a)(13)Individual #1's prescribed Montelukast 10mg tablet was discontinued on 1/28/2022. Individual #1's April 2022 Medication Administration Record is initialed by staff, indicating 8 pm administrations from 4/01/22 through 4/21/2022. The medication was not present in the home.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.We use an electronic MAR. The staff accidently selected that medication when checking off on the other 8pm medications. On 4/22/22 a call to the pharmacy was made asking to discontinue the said medication from the MAR. The documentation from the doctor was sent over to the pharmacy. Once they received the proper documentation from the doctor, the medication was discontinued from the MAR. 04/22/2022 Implemented
6400.213(1)(i)Individual #1's record did not include identifying marks.Each individual's record must include the following information: Personal information, including: (ii) Identifying marks.On 4/21/22, the record was updated. 04/21/2022 Implemented
SIN-00172277 Renewal 03/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment, dated 8/22/19, was not completed in the following areas: General Requirements, Staffing, Staff Health, Day Services, and 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
6400.261(a)Individual #1 was admitted to the home receiving respite care on 11/1/19, and remained in respite care until discharged to a semi-independent living on 2/9/20.Respite care is temporary community home care not to exceed 31 calendar days in a calendar year.Pathways will comply with the 6400 guidelines as written. In the event that a similar situation arises in the future, Pathways will admit the individual on the 30th day of respite services into the Community Home and will coordinate billing accordingly with the funding source. [Additional POC information provided on 3/26/2020 by Residential Program Director: This citation can not be immediately corrected because the time has already passed. This was a unique situation due to the individual being denied consolidated waiver, having nowhere to go, and us receiving variances for him to be able to stay as respite. Therefore, he was not able to truly be admitted into the 6400 community home due to lack of funding. If a situation like this arises again, we will admit "programmatically" on the 30th day. Meaning, we will follow the 6400 guidelines for a regular admission but will bill according to the funding source. This has been added to our respite admission procedure on 3/6/20. [Immediately, the CEO or designee shall educate all staff person responsible for ensuring that respite care does not exceed 31 calendar days in a calendar year, in the implementation of the aforementioned procedures. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 3/30/20)] 03/06/2020 Implemented
SIN-00151726 Renewal 03/12/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #1 had a review of medications prescribed to treat symptoms of a diagnosed psychiatric illness completed on 2/8/18 and the next review completed on 5-24-18. Individual #1's review completed on 5/24/18 does not include a list of medications, the necessary dosages, or the reason for prescribing the medications. Individual #1 had a review of medications prescribed to treat symptoms of a diagnosed psychiatric illness completed on 8-30-18 and the next review completed on 12-13-18. Individual #2's had a review of medications prescribed to treat symptoms of a diagnosed psychiatric illness completed on 5-2-18 and the next review completed on 9-19-18. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The residential lead staff is responsible for scheduling and completing all appointments and follow-up appointments. They are also responsible for ensuring the documentation is filled out in its entirety by the doctor. The lead staff will submit written verification to the residential supervisor at the end of each month. The residential supervisor is then responsible for reviewing appointment logs and documentation to ensure exactitude by months end. The residential supervisor will submit written verification to the assistant director monthly. Individual #2 schedules her own appointments. The lead staff will ensure individual #2 knows what date her next appointment needs to be scheduled by. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons involved in ensuring medication reviews are completed timely with all required information of the requirements of 6400.163(c) and the process to ensure timely completion, with all required information and the review process. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 4/9/19)] 03/14/2019 Implemented
Article X.1007Direct Service Worker #1, date of hire 4-30-18, who resided outside of Pennsylvania prior to employment did not have a criminal history record check completed in accordance with the Older Adult Protective Services Act.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Direct Service Worker #1 was registered for FBI DOA fingerprints on March 14, 2019 and got printed during the first available time slot on March 19, 2019 (only print on Tuesdays and Thursdays) and are awaiting results from FBI. Human Resources Assistant Director will review all new hire and rehire personnel files within their first 5 days to double check compliance. [Direct Service Worker #1 had a criminal history record check through the Department of Aging's protective service office in accordance with the Pennsylvania Older Adults Protective Services Act completed on March 20, 2019. All other staff records were checked by the Human Resources of the agency and no other staff persons were identified as needing to completed additional background checks. Upon hire, the human resources department or designated staff person shall review staff persons new hire information to ensure all required criminal background checks are completed including background checks in accordance with OAPSA. Documentation of audits shall be kept. (DPOC by AES,HSLS on 4/12/19)] 03/14/2019 Implemented
SIN-00110820 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 11-7-16. 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 completed 4-9-16 for Individual #1 to the plan team members on 8-16-16. The program specialist provided the ISP review documentation completed 7-9-16 for Individual #1 to the plan team members on 8-16-16. The program specialist provided the ISP review documentation completed 10-9-16 for Individual #1 to the plan team members on 1-31-17.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
6400.195(e)(2)The restrictive procedure plan for Individual #1 did not include the single behavioral outcome desired stated in measurable terms. The restrictive procedure plan shall include: The single behavioral outcome desired stated in measurable terms. Individual #1's Restrictive Procedure Plan tracks attempts to use the phone inappropriately, which include using the phone outside of the pre-planned daily call times and using the phone to call 911, SPHS Crisis Response and Individual # 1's Mental Health Therapist for non-emergencies. These attempts are recorded daily and reviewed on a monthly basis, with the desired goal of zero attempts for a period of 6 consecutive months for either type of inappropriate phone use. We believe this already states measurable terms for each desired behavioral outcome. We will, however, be altering the measurable terms to include a baseline level of attempts, a desired change in percentage form to that baseline and the new, current data collected. 04/13/2017 Implemented
SIN-00101407 Unannounced Monitoring 08/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest fire department and ambulance were not on or by the telephones in the kitchen and staff office.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. A new Emergency Contact Phone List was created and put into place on 08/15/2016. The new Emergency Contact Phone List now includes a separate, 10-digit phone number for the nearest hospital, police department, fire department, ambulance and poison control center. These new Emergency Contact Phone Lists will be kept by each phone in the home with an outside line. (Note: A new, area specific, Emergency Contact Phone List was also created for all homes and put into place on 08/15/2016.)[All staff shall be educated that telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line and to monitor throughout the course of their daily duties and the replacement procedures if the telephone numbers become illegible or missing. (AS 1/25/17)] 10/14/2016 Implemented
6400.163(c)Individual #1 is prescribed medication for Depression, Psychotic Disorder and Anxiety. The most recent medication review with documentation by a licensed physician was completed on 3/24/16. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.* In the Violations Summary, Individual #1 is named as Dewayne ¿Greg¿ Austin, but the individual in question was Steven Rosepink. Individual #1 was seen by a licensed physician for a medication review on 09/01/2016. Residential Program Supervisor was re-trained on 55 PA Code Chapter 6400.163 (c) (Medication Review requirements) on 08/12/2016. Residential Program Supervisor will also use and update a ¿tickler file¿ to track all medical appointments, helping to ensure compliance with regulations. [At least quarterly for 1 year the Residential program director shall review a 25% sample of psychiatric medication reviews to ensure timely completion. (AS 1/25/17)] 10/14/2016 Implemented
SIN-00091069 Renewal 03/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The outside light on the back porch of the home was not operable. There is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Violation was corrected on 3/4/16, while the inspector was on-site. Operation of outside light on back porch is verified every night, as this is the primary walkway for staff & visitors. Operation of all lights is also verified as part of our Daily Communication Log. [Aforementioned procedures to verify that all rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents including documentation in the daily communication log will be implemented at all community homes. Within one month of receipt of the plan of correction. All staff working in community homes shall be educated on the procedures and documentation to ensure rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. At least quarterly daily communication logs shall be reviewed by the homes supervisor or designated management staff to ensure completion and that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. (AS 4/27/16)] 04/18/2016 Implemented
6400.71Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall were not posted on or by the telephone in the kitchen.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Violation was corrected on 3/4/16, after the inspector had left. The required phone number¿s were not posted on or by the telephone in the kitchen as Individual #1 has, at times, used these numbers to make inappropriate phone calls. To prevent this from being an issue in the future, proper posting of the required phone numbers will be verified as part of our Daily Communication Log.[Aforementioned procedures to verify that telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are on or by each telephone in the home with an outside line including documentation in the daily communication log will be implemented at all community homes. Within one month of receipt of the plan of correction. All staff working in community homes shall be educated on the procedures and documentation to telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are on or by each telephone in the home with an outside line. At least quarterly daily communication logs shall be reviewed by the homes supervisor or designated management staff to ensure completion and that telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are on or by each telephone in the home with an outside line. (AS 4/27/16)] 04/18/2016 Implemented
6400.163(c)Individual #1 a had a psychiatric medication review by a licensed physician on 2/27/15 and then again on 7/14/16. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.(Date range in violation corrected to 2/27/15 ¿ 7/14/15) - On 4/9/15, Individual #1 was admitted to Western Psychiatric Hospital. During this stay Individual #1 had a psychiatric medication review. A copy of the HCSIS Report was provided to the inspectors. We have also requested copies of Individual #1¿s records from that review, but have not received them yet. . In order to correct the issue of missing medical appointments, we have begun using a ¿tickler file¿ for all individuals which provides the most recent & upcoming appointments with all medical providers. This ¿tickler file¿ is digitally saved in a general location, to make it accessible, in case of need for emergency coverage. [The house supervisor will be responsible for scheduling appointments and updating the tracking system to ensure timely completion of psychiatric reviews by a licensed physician. At least monthly, Residential Managers will review the tracking system to ensure timely completion of psychiatric reviews by a licensed physician. (AS 4/27/16)] 04/18/2016 Implemented
6400.186(b)The program specialist and Individual #1 did not sign the ISP reviews for Individual #1, dated 4/10/15 to 7/9/15. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The ISP review for the period of 4/10/15 ¿ 7/9/15, which was signed by both the Program Specialist and Individual #1, was present in the Individuals¿ file. At the end of the exit interview, we sent a staff member to the Individuals¿ home and had that staff send us a photo of the above mentioned ISP review. This photo was immediately forwarded to the Lead Inspector via email. To prevent future issues, once all necessary signatures have been obtained, ISP reviews will be saved digitally, as back-up. [Immediately and at least quarterly, ISP reviews shall be reviewed by designated management person to ensure the program specialists and Individual sign and date the ISP reviews as required. Documentation of reviews of the IPS reviews shall be kept. (AS 4/27/16)] 04/18/2016 Implemented
SIN-00053758 Renewal 01/21/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(c)Individual #1's ISP, most recently updated 4/26/13, states that the individual "can be alone in any room of his home, except the kitchen, for fifteen minutes with staff in another part of the house. (The individual) should always be within hearing range of staff." On 12/24/13, Staff Person #1 and Staff Person #2 went into the garage area of the home leaving Individual #1 unattended inside the home. During the break which lasted 25 minutes, Staff Person #1 smoked marijuana. Staff person #2 notified Staff person #3, the residential program supervisor, on 1/4/14. The incident was not reported until 1/6/14. (c) The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. Supervisory staff was instructed to re-stress with direct care staff the need to report all incidents within the required 24 hours; if there is any doubt/question in their mind, in turn, they should not be thinking about the incident, but they must report it immediately. Additionally, all new staff has always been trained to report within required time frames. If, in the future an incident is reported past the required 24 hours, the point person will immediately complete the HCSIS report and the investigation will be initiated. 02/24/2014 Implemented
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 to get resigned by three individuals who reside at Poplar house. 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
6400.45(d)Individual #1's ISP, most recently updated 4/26/13, states that the individual "can be alone in any room of his home, except the kitchen, for fifteen minutes with staff in another part of the house. (The individual) should always be within hearing range of staff." On 12/24/13, Staff Person #1 and Staff Person #2 went into the garage area of the home leaving Individual #1 unattended inside the home. During the break which lasted 25 minutes, Staff Person #1 smoked marijuana. (d) The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). Staff has been instructed to maintain required ratios as per the ISP's at all times to provide necessary supervision. Both staff involved in this incident were suspended and consequently terminated from employment. 02/24/2014 Implemented
6400.106The two most recent furnace inspections were completed on 4/5/12 and 4/29/13.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 4/29/13 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-00227741 Unannounced Monitoring 07/14/2023 Compliant - Finalized
SIN-00225262 Unannounced Monitoring 05/18/2023 Compliant - Finalized
SIN-00221693 Renewal 03/28/2023 Compliant - Finalized
SIN-00042692 Renewal 09/17/2012 Compliant - Finalized