Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00211620 Renewal 09/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1, annual physical examination completed on 10/7/2021, did not include a vision screening. The physician documented the vision screening as "unable to do." Individual #1's most recent vision screening was completed on 10/6/2020.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Physical updated to simplify the vision/hearing requirements per the 2380 regulations. Updated physical attached. The Program Specialist will provide the caregiver with a clarification form for vision/hearing check up needs to be submitted to the health care provider. Attached is the clarification form. 09/26/2022 Implemented
2380.111(c)(5)Individual #2 had a tuberculin skin test that was read on 3/22/2021 by a medical assistant.2380.111(d)- Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.To ensure that the TB is read by the proper licensed health care professional, the reminder letter that is sent by the program specialist will state the following: As per regulation the Mantoux Tuberculin skin test needs to be applied and read by a licensed health care professional such as an MD, RN, LPN, CRNP, or PAC. And the credentials must be clearly recorded. The reminder letter is attached. 09/26/2022 Implemented
SIN-00194219 Renewal 10/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)The Program Specialist provided Individual #1's assessment, dated 05/13/21, to the individual plan team members on 05/13/21. The annual individual plan meeting occurred on 06/07/21.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Ensure annual Pathways assessments are completed in time to provide at minimum 30 days prior to Annual ISP meetings, to identified team members, based on the date of the last Annual ISP meeting. Assessment due dates to not exceed 6 months from Annual ISP Meeting but also not impede on 30-day advance notice of assessment results. If completed outside of 90-Days from the Annual ISP meeting, assessment results will be reviewed at 30 ¿ 90-Day mark for any identified changes, notification of changes or no changes identified to be sent to identified team members. 10/14/2021 Implemented
SIN-00179092 Renewal 11/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #3's physical examination completed on 7/24/2019 recommended a follow-up appointment with an optometrist; however, there was not a follow-up appointment.The physical examination shall include: Vision and hearing screening, as recommended by the physician.- Pathways Physical examination form has been updated to include (1) whether follow-up is required for specialized appointments. We are clarifying to mark ¿None¿ if not, If so, specific specialist appointment options are outlined, including ¿other¿ line to require that if follow-up is required, the nature of the appointment is specified and physician must fill out specific date that appointment must be completed by. - Program Specialists will track all chart document completion with the Assistant Director assigned the responsibility for verifying completion. The Assistant Director will document that the specialized appointment was followed up by the Individual¿s guardian/program or parent and that information will be added to the individual¿s chart. If the appointment is not completed by the specified date the individual will not be allowed to attend the program until said appointment is completed (notification of due dates will continue to be provided to individual/families by Program Specialist/Assistant Director) - The ATF has a Master tracker system that will be utilized to monitor the process. The tracker will be monitored weekly by the Assistant Director and assigned the Program Specialist to ensure strict adherence to the due dates. [Immediately, the CEO, or designee, shall complete an audit of all individual physical examinations to ensure that hearing and vision screenings have been completed. If a hearing or vision screening was not completed at the time of the physical examination, a follow-up appointment with a specialist shall be scheduled. Documentation of the individual file audit shall be kept. At least quarterly, for a period of one year, the CEO, or designee, shall conduct a random audit of 25% of individual records to ensure that hearing and vision screenings have been completed. Documentation of the audit shall be kept. DPOC by HDKP, HSLS, on 12/11/2020]. 11/20/2020 Implemented
2380.33(b)(2)Individual #1's ISP, last updated 10/15/2020, states that Individual #1 can temper water with cues and needs to be checked by staff; however, Individual #1's Assessment, dated 1/10/2020, indicates the individual is independent with tempering water. Individual #2's ISP, last updated 8/13/2020, states "if it unclear" if the individual would ingest a substance that has "no odor or smells like candy;" however, Individual #2's Assessment, dated 7/3/2020, indicates Individual #1 is independent with poisonous materials.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.- All Assessments will be and are to be completed in accordance with the ISP; comparative analysis will be completed prior to completion. - Assessments will be completed assuming safeguards in place did not exist (i.e. if water temperature control was not implemented/in good repair at ATF) - If differences are determined within the assessment and in comparison with the most recent ISP, and verified to be correct, notification will be sent along with assessment results to the Supports Coordinator as well as the treatment development team outlining the recommended variations for review and approval. [Immediately, the CEO, or designee, will complete a review of all Individual Support Plans (ISPs) and Individual Assessments to ensure that there are no discrepancies. Documentation of the review shall be kept. If discrepancies are identified, the CEO, or designee, shall notify the Plan Team Lead responsible for writing the ISP. Documentation of communication of discrepancies shall be kept. At least quarterly, for a period of one year, the CEO, or designee, shall conduct a random audit of 25% of all participant ISPs and Individual Assessments to ensure that there are no discrepancies. Documentation of audit shall be kept. DPOC by HDKP, HSLS, on 12/11/2020]. 11/20/2020 Implemented
2380.39(b)(1)Chief Executive Officer, date of hire 12/7/2016, did not complete training for the annual training year January 1, 2019 to December 31, 2019.The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.- The CEO of Pathways is currently in compliance with the required 12 hours of trainings for 2020 calendar year. - The Pathways Human Resource Team is assigned responsibility to ensuring that all mandated trainings are completed by administrative staff in accordance with the appropriate regulatory entity, i.e.., 2380s and 6100s. [Immediately, the CEO, or designee, will complete an audit of all employee files to verify that all employees are obtaining required annual training hours. Documentation of audit shall be kept. Immediately, the CEO, or designee, will establish and maintain a schedule for the remaining 2021 training year that will total 24 total annual training hours for the CEO, 12 hours for the 2021 training year and 12 hours for the missed training in the 2019 training year. Documentation of 24 hours of annual training shall be kept. At least quarterly, for a period of one year, the CEO, or designee, shall conduct an audit of all staff files to ensure that annual training requirements are being met. Documentation of audit shall be kept. DPOC by HDKP, HSLS, on 12/11/2020]. 11/20/2020 Implemented
2380.182(c)Individual #2, date of admission 6/7/2016, had an annual Individual Support Plan (ISP) meeting on 3/30/2020; however, the assessment provided was completed 7/3/2019, over eight months prior to the meeting. Individual #3, date of admission 5/2/2019, had an annual ISP meeting on 2/18/2020; however, the assessment provided was completed on 6/17/19, over eight months prior to the meeting.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.- Tracking has been completed to compare assessment completion due dates as of 11/16/2020 - The Assistant Director and the assigned Program Specialist have completed an internal review of all assessments and any assessment completed outside of stipulated timeframe of 6 months from the ISP Meeting date will be resent with documentation of any result variations that have occurred within 6 months of ISP Meeting due date. [Immediately, the CEO, or designee, shall implement a tracking system to ensure that Individual Assessments utilized for annual ISP meetings are current. Within 30-days, the CEO, or designee, will train the Assistant Director and Program Specialist on the tracking system. At least quarterly, for a period of one year, the CEO, or designee, will complete an audit of 25% of all individual Assessments to ensure that the information contained in the individual Assessment is current. Documentation of the audit shall be kept. DPOC by HDKP, HSLS, on 12/11/2020]. 11/16/2020 Implemented
SIN-00137141 Renewal 06/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(1)The assessment for Individual #1, completed 1-4-18, was not completed by the program specialist. The assessment for Individual #2, completed 9-6-17, was not completed by the program specialist. The assessment for Individual #3, completed 12-15-17, was not completed by the program specialist. The assessment for Individual #4, completed 12-15-17, was not completed by the program specialist.The program specialist shall be responsible for the following: Coordinating and completing assessments.All individuals' assessments will be completed by the Program Specialist. The assessment was modified to reflect this change (old assessments had been completed by direct care staff and reviewed by the program specialist). The next assessment due for completion will be submitted as supporting documentation that this change occurred. [Immediately, upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. Upon completion for 1 year, the CEO or designee shall review all individuals' assessment to ensure completion by the program specialist(s) with all required information. (AS 7/18/18)] 07/02/2018 Implemented
2380.181(e)(12)The assessment for Individual #1, completed on 1-4-18, did not include recommendations. The assessment for Individual #2, completed 9-6-17, did not include recommendations. The assessment for Individual #3, completed 12-15-17, did not include recommendations. The assessment for Individual #4, completed 12-15-17, did not include recommendations.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Assessment was modified to include recommendations for training; vocational programming; and competitive integrated employment. All future assessments will utilize the new modified version. The next assessment due for completion will be submitted as supporting documentation that assessment was modified. [Immediately, upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the requirements of individual assessments as per 2380.181(e)(1)-(14). Documentation of the training shall be kept. Immediately, the program specialist shall audit all individuals' current assessments to ensure all required information is included including Individuals' #1, #2, #3 and #4s' assessments. Upon completion for 1 year, the CEO or designee shall review all individuals' assessment to ensure completion by the program specialist(s) with all required information as per 2380.181(e)(1)-(14) including recommendations for specific areas of training, vocational programming and competitive community-integrated employment. Documentation of all audits shall be kept. (AS 7/18/18)] 07/02/2018 Implemented
SIN-00092568 Renewal 07/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(b)The physical examination completed for Direct Service Worker #1 was not dated by the physician. The most recent physical examination for Direct Service Worker #1 completed, signed and dated by a physician was on 2/10/14.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.Human Resources Assistant Director or designee will audit all physical forms to ensure that the proper and all required sections are filled out by the provider. This process has been put into place and will continue from this point forward. [Direct Service Worker #1's physical examination was dated 2-5-16. Within one month of the plan of correction, the CEO shall develop and implement policies and procedures to ensure all staff physical examinations include all required information as per 2380.113(b) and 2380.113(c)(1)-(4) and train staff responsible to ensure all staff physical examinations include all required information on the policies and procedures and 2380.113(b) and 2380.113(c)(1)-(4). At least quarterly, the CEO or assistant director will review a 25% sample of staff physical examinations to ensure all required information included. Documentation of policies, procedure, trainings and reviews of physical examinations shall be kept.(AS 8/26/16)] 08/12/2016 Implemented
2380.181(a)The two most recent assessments for Individual #1 were completed on 3/31/16 and 3/13/15.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Program Specialist will ensure that all assessments are updated annually. If any individual is absent and staff are not able to physically observe skills, to ensure that record regulation is met, the Program Specialist, will contact individual's team members to gauge individual's skills. [Within 10 days of receipt of the plan of correction, the CEO will develop and implement policies and procedures to include a tracking system to ensure all individuals' assessments are completed within the required timeframes. Within 30 days of receipt of the plan of correction, the CEO will train the program specialist on the policies and procedures and tracking system to ensure individuals' assessments are completed within the required timeframes. At lease quarterly for 1 year the CEO or assistant director shall review completed assessments to ensure policies and procedures and tracking system is being implemented by the program specialist and all individuals' assessments are being completed within the required timeframes. Documentation of policies, procedures, tracking, trainings and reviews shall be kept. (AS 8/26/16)] 08/12/2016 Implemented
SIN-00079602 Renewal 07/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)The program specialist did not provide the assessment to the entire team for Individual #1's assessment completed on 2/25/15, Individual #2's assessment completed on 1/9/15 and Individual #3's assessment completed on 5/1/15.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).All Program Specialists and Supervisory staff received training on regulation and forms adjusted to show this.[Documentation of above mentioned training completed on 7/30/15 of 2 hour training was submitted to the department. Documentation of assessment being sent to additional team members for Individual #1 and #2 was sent to the Department. As per conversation with director on 8/13/15 ATF Director, Assistant Director/program specialist reviewed all Individuals records and send assessments to the entire team for all individuals as necessary. ATF Director will continue to monitor all Individuals documentation for the next 6 months to ensure the Program Specialist has sent assessment to the entire team. Assistant Director/program specialist developed a "sent to" sheet to ensure all team members are receiving assessments as required. (AS 8/12/15)] 07/17/2015 Implemented
2380.186(d)The program specialist did not provide ISP review documentation to the entire team for Individual #1's reviews completed 9/14/14, 12/14/14, 3/14/15 and 6/14/15; Individual #2's reviews dated 2/11/15 and 5/11/15 and Individual #3's reviews dated 1/10/15 and 4/10/15.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.All Program Specialists and Supervisory staff received training on regulation and forms adjusted to show this.[Documentation of above mentioned training completed on 7/30/15 of 2 hour training was submitted to the department. Documentation of ISP review documentation being sent to additional team members for Individual #1 and #2 was sent to the Department. Assistant director/program specialist w reviewed all Individuals records and send ISP Review documentation from the past 6 months to the entire team for all Individuals as necessary. ATF Director will continue to monitor all Individuals documentation for the next 6 months to ensure the Program Specialist has sent the ISP review documentation to the entire team.Assistant Director/program specialist developed a "sent to" sheet to ensure all team members are receiving required documentation. (AS 8/12/15)](AS 8/12/15)] 07/17/2015 Implemented
SIN-00066246 Renewal 07/15/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(d)Staff Person #1, hired 10/21/13 did not receive training in the areas of services for people with disabilities and program planning and implementation until 1/6/14. Staff Person #2, hired, 12/10/13 did not receive training in the areas of services for people with disability and program planning and implementation until 3/10/14. Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.ATF Director (Jennifer Scott) and Assistant Director (Susan Fox) reviewed applicable regulation on 7/15/14. See attached training sheet. Training policy was updated by ATF Director, Jennifer Scott, to reflect the regulation requirements on 7/15/14. See bold/underlined statement in attached policy. Next new hire completed the training per regulated timelines by Susan Fox, Assistant Director. See attached copy of training. 07/23/2014 Implemented
SIN-00049838 Renewal 04/09/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)The annual physical examination for Individual #1, dated 10/1/2012, did not include the hearing and vision screening results. Repeat Violation-4/13/2012(c)  The physical examination shall include:(4)  Vision and hearing screening, as recommended by the physician.Training on the physical examination vision/hearing requirements was received by all parties responsible for review of the exams when they came in. There is a signed training sheet on record. I also have a copy of the most recent physical exam since inspection and the vision/hearing is complete. The individual in question at inspection has his physical due on October 1, 2013.--Jennifer Scott, Director [The Director will ensure that all individuals physical examinations are reviewed to ensure they were completed timely and include all required information by 8/15/13. (CHG 7/25/13)] 06/21/2013 Implemented
2380.173(1)(ii)The record for Individual #2 did not include personal information regarding identifying marks. According to health summaries within the record, Individual #2 has a surgery scar at his/her stoma site.(1)  Personal information including: (ii)   The race, height, weight, color of hair, color of eyes and identifying marks.Training on the personal information to be included in the record was received by all parties responsible for ensuring all pertinent information is included on the face sheet when the individual is enrolled and updated as needed. There is a signed training sheet on record. On file is the updated face sheet for individual #2.--Jennifer Scott, Director [The Director will ensure that all required Personal information is audited and included on every individual's record by 8/15/13. (CHG 7/25/13)] 06/21/2013 Implemented
2380.181(f)The annual assessment for Individual #2, dated 6/13/12, was not provided to the Supports Coordiantor and plan team members at least 30 days prior to the annual ISP meeting. The date of the annual ISP meeting was 6/28/12.(f)  The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Training on the assessment completion and dissemination requirements was received by all parties responsible for dissemination of the assessment to team members. There is a signed training sheet on record. There is letter on record for the individual that was next due for assessment, indicating required timeframes being met.--Jennifer Scott, Director [The Director will audit individual records monthly to ensure that the annual assessments are provided to the Support Coordinator and plan team members at least 30 days prior to the annual ISP meetings. (CHG 7/25/13)] 06/21/2013 Implemented
SIN-00230737 Renewal 09/19/2023 Compliant - Finalized
SIN-00157682 Renewal 06/21/2019 Compliant - Finalized
SIN-00117285 Renewal 07/12/2017 Compliant - Finalized