Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00131721 Renewal 03/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)An unannounced fire drill was not held in March 2017. An unannounced fire drill shall be held at least once a month. This was identified in May 2017. In June 2017 PathWays Residential Program implemented a new fire drill procedure. A yearly fire drill schedule was implemented. The supervisors are the only ones who receive the schedule to ensure they remain unannounced. 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 and reviewing fire drills and fire drill records 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)] 06/01/2017 Implemented
6400.112(c)The written fire drill record for the fire drill held in May 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 and reviewing fire drills and fire drill records 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
SIN-00075641 Renewal 02/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1 refused his prostate exam on 8/8/14, and there was no documentation regarding continued attempts to train the individual on the need for health care. If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. All residential supervisors and managers were retrained on Documenting Medical Procedures Refusals and Retraining on 3/13/15. Copies included for your review. Individual in question was retrained on prostate exam process and desensitization. Copy included for your review.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. [CEO or designee will continue to educate at least monthly Individual #1 and other individuals being served by the agency about the need for health care when an individual refuses medical examinations or treatment and document the attempts in the individual's records. (AS 4/20/15)] 03/13/2015 Implemented
6400.213(1)(i)The personal information in Individual #1's record did not include religious affiliation. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.All residential supervisors and managers were retrained on documentation completion dated 3/13/15. Copies included for your review. Record in question was updated with the appropriate information. Copy included for your review. 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. 03/13/2015 Implemented
SIN-00221694 Renewal 03/28/2023 Compliant - Finalized
SIN-00186622 Renewal 04/22/2021 Compliant - Finalized
SIN-00151728 Renewal 03/12/2019 Compliant - Finalized
SIN-00106220 Unannounced Monitoring 11/10/2016 Compliant - Finalized