Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231211 Unannounced Monitoring 09/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(d)During the inspection conducted 9/15/2023 the first aid kit, which is located unlocked on the medication cabinet and accessible to the individuals, contained Non-Aspirin Acetaminophen 325mg. Individual #1, Individual #2, and Individual #3 are assessed to be unable to self-administer medication.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.On 9/15/23, the non-aspirin acetaminophen from the First Aid kit was removed according to PathWays policy for disposing of medications. 09/27/2023 Implemented
6400.165(a)Individual #1 is prescribed Acetaminophen 325mg, witch instructions to take 1 tablet by mouth every 6 hours as needed for pain or temperature over 100°F, take with applesauce. During the inspection conducted 9/15/2023, Individual #1 had a bottle of Equate Extra Strength Acetaminophen 500mg, with instructions to take 2 caplets (1,000mg) every 6 hours while symptoms last, present with her medications without an order from an authorized prescriber.A prescription medication shall be prescribed in writing by an authorized prescriber.On 9/15/23, the Home Coordinator removed the medication from the home in accordance with PathWays policy for disposing of medications. On 9/18/23, after speaking with the prescribing doctor, the Director of Community Health faxed the over-the-counter order to their office where they discontinued the OTC order for Acetaminophen since she has a PRN prescription for this medication already. The Home Coordinator, on 9/15/23, also confirmed the individual had not been administered this medication. 09/27/2023 Implemented
SIN-00227742 Unannounced Monitoring 07/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(a)On 7/14/2023 there were road closure signs on both ends of the street, where the home is located. There were multiple outside lines hanging down over the roof of the home dipping down in the backyard, about a foot over a metal fence. Staff advised one of the wires was an active power line and stated the fire department recommended staff to continue to monitor the line to ensure it stays above the metal fence, due to electrical current. The lines also dropped down across the sidewalk leading from one of the exits from the home, this sidewalk could not be used as someone would have been able to grab the electrical wire or hit it with their head. The Chief Executive Office designee confirmed that he was advised of the incident but had not come to see the damage in person and the individuals were not relocated prior to the inspection. (Repeated violation-5/18/2023)There shall be one chief executive officer responsible for the home or agency. In the morning of 7/14/23, the maintenance department cut up the tree that had fallen from the neighbor's yard. The Fleet and Facilities Director had reported that West Penn Power and the City of Washington Fire Department had both indicated the site was safe. Upon licensing's recommendation to relocate the individuals, they were immediately relocated to another site, per the emergency plan, until a handicap accessible hotel was identified. The individuals from this home stayed at the hotel until the evening of 7/15/23 when it was confirmed by the Residential Director/CEO designee that West Penn Power had fixed the issue. 07/15/2023 Implemented
SIN-00225263 Unannounced Monitoring 05/18/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(3)On 5/18/2023 the chief executive officer did not maintain safety and protection of the individuals. Individual #1 has a G-Tube and their medication administration record documented the route of administration as by mouth for multiple medications and the individual support plan, last updated 9/27/2022, states Individual #1 does not take anything by mouth. Individual #2 was prescribed Polyethylene Glycol Powder to be administered on days where she did not have a bowel movement. individual #2's bowel movement documentation recorded she did not have a bowel movement 5/01/2023 thru 5/05/2023, 5/07/2023 thru 5/12/2023, and 5/14/2023 thru 5/16/2023 and the medication was not administered. On 5/18/2023 there were multiple medications unlocked and accessible to the individuals and expired medications in the home. Individual #2 is prescribed Nayzilam Spray 5mg, use 1 dose intranasally as needed for seizures lasting greater than 5 minutes, which was not present in the home on 5/18/2023.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. On 5/18/23 the Director of Community Health/RN sent orders to the PCP for Individual #1 to discontinue all PO orders and replace with proper route (peg tube). On 5/19/23 the Director of Community Health and Residential Director (CEO) audited all medications and medication administration records for all 3 individuals. All PRN medications no longer needed were discontinued by the PCP and removed from the MAR. All PRN medications listed on the MAR were reordered and delivered by the pharmacy. All medications and creams were in locked cabinet. The Director of Community Health/RN sent orders to the PCP for Individual #2. On On 5/26/23 the Adult Services Trainer and Program Manager completed another audit for all 3 individuals. Final orders were submitted for Individual #3 to PCP for pharmacy. On June 6, 2023 Individual #1 had appointment with his PCP and a follow-up on June 12, 2023. On June 7, 2023, the Residential Director (CEO) and Adult Services management participated in a re-training on the medication administration regulations which included the 5 rights, PRN medications, storing medications, disposing of expired and discontinued medications, and ensuring prescribed medications are in the home. All Direct Support Professionals will be retrained on the medication administration regulations, including storing of medications by July 7, 2023. The Home Coordinators will continue to do weekly audits and Program Managers, monthly audits. The Residential Director will conduct sampling audits on a quarterly basis. 07/07/2023 Not Implemented
6400.163(d)On 5/18/2023 the following medications were observed unlocked and located in Individual #1's bedroom in the top dresser drawer: Desitin Cream 0.13%, Aloe Vesta Ointment Protect, Vitamin A&D Ointment, Petroleum Jelly Gel, and Vaseline Lip Therapy. The individual is unable to self-administer medications.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.On 5/18/23, the Residential Director, Director of Community Health, and Adult Services Trainer removed the medications from the top dresser drawer in Individual #1's bedroom and placed them in a locked cabinet. The Home Coordinator received individual feedback re: ODP Medication Administration Training and protocol, including proper storage of all medications. 07/07/2023 Not Implemented
6400.163(h)On 9/06/2022 Individual #1 was prescribed Diphenhydramine 50mg capsule, take 1 capsule by mouth every 8 hours as needed for 20 days. On 5/18/2023 the medication was present in Individual #1's medication storage. On 5/18/2023 the following expired medications prescribed to individual #1 were observed in the home: Ondansetron 4mg ODT tablet expired 3/27/2023, Antacid/Anti-Gas expired 3/27/2023, Siltussin SA 100/5ml Syrup expired 4/21/2023, and Duoderm CGF Extra Thin expired 3/27/2023. On 5/18/2023 the following expired medications prescribed to individual #2 were observed in the home: Chloraseptic 6-10mg Lozenge expired 2/27/2023 and Duoderm CGF Extra Thin expired 3/27/2023.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.On 5/18/23 the Director of Community Health and Residential Director removed all expired medications from the home and followed PathWays policy for disposing of expired and discontinued medications. 07/07/2023 Not Implemented
6400.165(b)On 5/18/2023 the following pro re nata medications prescribed to Individual #1 were not in the home: Albuterol Nebulizer 0.083%, Triaminicol, Loperamide 2mg Capsule, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, and SM Stomach Sus 525/30ml. On 5/18/2023 the following pro re nata medications prescribed to Individual #2 were not in the home: Acetaminophen 325mg tablet, Nayzilam 5mg spray, Pseudoephedrine 30mg tablet, and Senna-Plus 8.6-50mg tablet.A prescription order shall be kept current.On 5/19/23, the Director of Community Health and Residential Director conducted an audit of the Medication Administration Record and medications in the home. An order was sent to the pharmacy to discontinue PRN medications that were no longer needed. The Director of Community Health reordered current PRN medications that were not in the home. 07/07/2023 Not Implemented
6400.166(a)(4)On 5/18/2023 Individual #1's May 2023 medication administration record did not include the following medication names: Ocusoft Lid Pad Original and Hydrocortisone 1% cream.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. 05/18/2023 Not Implemented
6400.166(a)(5)On 5/18/2023 Individual #1's May 2023 medication administration record did not include the strength of the medication for the following: Ocusoft Lid Pad Original and Hydrocortisone 1% Aloe cream.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. 05/18/2023 Not Implemented
6400.166(a)(6)On 5/18/2023 Individual #1's May 2023 medication administration record did not include the dosage form for the following medications: Ocusoft Lid Pad Original and Hydrocortisone 1% Aloe cream.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. 05/18/2023 Not Implemented
6400.166(a)(7)On 5/18/2023 Individual #1's May 2023 medication administration record did not include the dose for the following medications: Ocusoft Lid Pad Original, Hydrocortisone 1% Aloe cream, Antacid/Anti-Gas, Antidiarrhea 2mg tablet, Bacitracin Ointment 500/gm, Epinephrine 0.3mg injection, Triaminicol, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, and SM Stomach Sus 525/30ml. Individual #2's May 2023 medication administration record did not include dose for the following medications: Acetaminophen 325mg tablet, Antacid/Anti-gas, Chloraseptic 6-10mg Lozenge, Citrucel Powder SF Orange, Hydrocortisone Cream 1%, Ibuprofen 200mg tablet, Metamucil SF Orange, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, QC Pink Bismuth 236ml, Senna-Plus 8.6-50mg tablet, and Siltussin DM LIQ DAS.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.On 5/19/23, the Residential Director and Director of Community Health reviewed the MAR and medications. On 5/19/23, The Director of Community Health contacted the doctor's office to send updated orders to the pharmacy. The MAR has been updated to include the doses. 07/07/2023 Not Implemented
6400.166(a)(8)Individual #1's individual support plan, last updated 9/27/2022 states he does not take anything by mouth and staff place meds in feeding tube. On 5/18/2023 Individual #1's May 2023 medication administration record documented the following medications to be given by mouth as the route of administration: Fleqsuvy Sus 25mg/ml, Fluoxetine Sol 20mg/5ml, Polyethylene Glycol Powder 3350 NF, Risperidone Sol 1mg/ml, and Loperamide 2mg capsule. Individual #1's May 2023 medication administration lists Doxazosin 4mg tablet, take 1 tablet via peg tube every day for high blood pressure, and does not give specifics on how the medication is prepared for that route of administration. Individual #1's May 2023 medication administration record states the individual is prescribed Ibuprofen Sus 100/5ml with instructions to give 20ml with food or milk three times a day as needed. Individual #1 is prescribed Petroleum Jelly Gel, Vitamin A&D Ointment, Aloe Vesta Ointment, and Lidocaine Cream 4% and the route of administration is documented as "affected area" on Individual #1's May 2023 medication administration record and does not provide detail on where the affected areas are. Individual #1's May 2023 medication administration record did not include the route of administration for the following medications: Ocusoft Lid Pad Original, Antacid/Anti-Gas, Antidiarrhea 2mg tablet, Bacitracin Ointment 500/gm, Epinephrine 0.3mg injection, Triaminicol, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, and SM Stomach Sus 525/30ml. Individual #2's May 2023 medication administration record did not include the route of administration for the following medications: Acetaminophen 325mg tablet, Antacid/Anti-gas, Chloraseptic 6-10mg Lozenge, Citrucel Powder SF Orange, Hydrocortisone Cream 1%, Ibuprofen 200mg tablet, Metamucil SF Orange, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, QC Pink Bismuth 236ml, Senna-Plus 8.6-50mg tablet, and Siltussin DM LIQ DAS.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.On 5/18/23, the Director of Community Health contacted the prescribing doctors and pharmacy to update the orders for the route to be via peg tube rather than by mouth. On 5/19/23, new labels were provided for most medications and the MARs for those medications were updated with the appropriate route. While at the PCP on 6/5/23, the Home Coordinator followed up with the PCP for the additional updated orders to be sent and their office said they had to wait because they were sending him to the ER due to his pulse ox being low and a fever. They will not send the orders over until his follow up appointment with the PCP on 6/12/23. 07/07/2023 Not Implemented
6400.166(a)(9)On 5/18/2023 Individual #1's May 2023 medication administration record did not include the frequency of administration for the following medications: Ocusoft Lid Pad Original, Hydrocortisone 1% Aloe cream, Antacid/Anti-Gas, Antidiarrhea 2mg tablet, Bacitracin Ointment 500/gm, Epinephrine 0.3mg injection, Triaminicol, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, and SM Stomach Sus 525/30ml. Individual #2's May 2023 medication administration record did not include the frequency of administration for the following medications: Acetaminophen 325mg tablet, Antacid/Anti-gas, Chloraseptic 6-10mg Lozenge, Citrucel Powder SF Orange, Hydrocortisone Cream 1%, Ibuprofen 200mg tablet, Metamucil SF Orange, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, QC Pink Bismuth 236ml, Senna-Plus 8.6-50mg tablet, and Siltussin DM LIQ DAS.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.On 5/19/23, the Director of Community Health and Residential Director reviewed the MAR and medications. On 5/19/23, The Director of Community Health contacted the doctor's office to have updated orders sent to the pharmacy. The MAR has been updated to include the frequency of administration. 07/07/2023 Not Implemented
6400.166(a)(10)On 5/18/2023 Individual #1's May 2023 medication administration record did not include administration times for the following medication: Ocusoft Lid Pad OriginalA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.PathWays disagrees with this violation: On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. 05/18/2023 Not Implemented
6400.166(a)(11)On 5/18/2023 Individual #1's May 2023 medication administration record did not include the diagnosis or purpose for the following medications: Ocusoft Lid Pad Original, Hydrocortisone 1% Aloe cream, Petroleum Jelly Gel, Aloe Vesta Ointment Protect, and Vaseline Lip Therapy. Individual #3's May 2023 medication administration record did not include diagnosis or purpose for the following medications: Chlorhex Glu Sol 0.12% and Ocusoft Lid Pad Original.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.On 5/19/23, the Residential Director and Director of Community Health Reviewed the medication and MARs in the home. These treatments and the diagnosis/purpose were added to the MAR on 5/24/23. 05/24/2023 Not Implemented
6400.166(a)(12)On 5/18/2023 Individual #1's May 2023 medication administration record did not include the date and time of medication administrations for the Ocusoft Lid Pad Original, rub each eye with side-to-side strokes, then rinse with water every day for eye care.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. 05/18/2023 Not Implemented
6400.166(a)(13)On 5/18/2023 Individual #1's May 2023 medication administration record did not include name and initials of the person who administered the Ocusoft Lid Pad Original 5/01/2023 through 5/18/2023.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.On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. 05/18/2023 Not Implemented
6400.167(a)(1)Individual #2 is prescribed Polyethylene Glycol Powder 3350 NF, mix ½ capful (8.5gm) with 4-8 oz of fluid and give at bedtime as needed if no bowel movement. individual #2's bowel movement documentation records no bowel movements from 5/01/2023 thru 5/05/2023, 5/07/2023 thru 5/12/2023, and 5/14/2023 thru 5/16/2023 and the medication was not administered at all in May 2023.Medication errors include the following: Failure to administer a medication.On 5/19/23, the Community Health Director requested a medication refill for Polyethylene Glycol Powder 3350 NF, mix ½ capful (8.5gm) with 4-8 oz of fluid and reviewed the bowel movement chart to identify if it needed administered on 5/19/23. Management validated that all staff had their ODP medication administration training. EIM report submission overlooked; submitted 6/10/23 (9229899). 07/07/2023 Not Implemented
6400.182(c)Individual #1's individual support plan, last updated 9/27/2022, states the route of administration by mouth for the following medications: Propranolol 60mg tablet, Fiber Lax 625mg tablet, Fluoxetine HCL 40mg capsule, Baclofen 10mg tablet, Lorazepam 0.5mg tablet, and Finasteride 5mg tablet. The plan also states the individual does not take anything by mouth and staff place meds in feeding tube.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.After the 9/27/22 ISP, several contacts with Support Coordinator(s) by the Clinical Specialist and Director of Community Health regarding Individual #1's changing needs/ISP updates occurred, in addition to a team meeting held in early March. On 6/1/23, the Director of Community Health emailed the Supports Coordinator for additional follow-up. After receiving an out of office message, the Director of Community Health emailed the SC Supervisor who said to follow up with the SC. The Director of Community Health is awaiting a reply from the SC. 07/15/2023 Implemented
SIN-00221692 Renewal 03/28/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill held on 5/29/22 does not include the time.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. Staff will be retrained on the proper procedures for completing a fire drill. Management will be trained on expected monitoring of fire drills. 05/15/2023 Not Implemented
6400.163(a)At 12:00 PM on 3/29/23, in Individual #1's medication box, there was a bottle of Nystatin Topical Powder was in a plastic bag with a pharmacy label of "Hydrocort 1% Aloe, apply topically to affected area every day."Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The nystatin powder was removed from the bag labeled "Hydrocort 1% Aloe, apply to the affected area every day." 05/31/2023 Not Implemented
SIN-00186620 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Direct Service Worker #1 had a Mantoux tuberculin screening that was administered on 8/3/20 by a certified medical assistant and read by at medical assistant on 8/5/20. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Pathways contacted the Office Manager for Washington Health System Occupational Medicine, Pathways will furnish the physical and Tb form with more pronounced indication as to 55 PA Code Chapter 6400.151(c)(2) and when calling to schedule appointments Pathways staff will point out, so it can be noted on the appointment for the provider to see that the TB must be placed and read by an RN or higher, licensed health care provider. 05/05/2021 Implemented
6400.182(c)Individual #1's assessment completed on 9/15/20 states that the individual does not avoid heat sources. Current ISP with a plan last updated date of 4/21/21, states that Individual #1 recognizes and avoids heat sources and knows the potential dangers.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 4/23/21 the Clinical Specialist emailed the SC to make the correction in the ISP. The Clinical Specialist is responsible for completing the annual assessments prior to the ISP meetings. In the ISP meeting the Clinical Specialist will ensure all the information is accurate in the ISP. Once we receive the finalized ISP, the Clinical Specialist will review for accuracy. If something is not correct, the Clinical Specialist will email the SC to make the change. 04/23/2021 Implemented
SIN-00172276 Renewal 03/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment, dated 8/30/19, was not completed in the following areas: General Requirements, Staffing, Staff Health, ISP Development Participation, Provider Services, 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
SIN-00110819 Renewal 03/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment was completed on 10-18-16 and the agency's certificate 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
SIN-00101409 Unannounced Monitoring 08/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Telephone 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)] 08/15/2016 Implemented
6400.141(c)(7)The two most recent gynecological examinations for Individual #1 were completed on 3/31/16 and 3/12/15.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Residential Program Supervisor was re-trained on 55 PA Code Chapter 6400.141 (Individual Health requirements) on 08/18/2016. Residential Program Supervisor and Residential Senior Supervisor were also re-trained on 55 PA Code Chapter 6400.143 (Refusal of Treatment requirements) on 08/18/2016, in the event a refusal occurs. 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 the tracking system and a 25% of physical examination to ensure timely completion. (AS 1/25/17)] 08/18/2016 Implemented
SIN-00091068 Renewal 03/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)The "cash on hand" form for Individual #1 dated, 2/29/16 read "cash count in line 2 should be $288.93." The actual cash counted on 2/29/16 totaled $228.93. There is no documentation for the $60.00 disbursement. The "cash on hand" form for Individual #2 dated, 1/16/16-2/16/16 read a balance of $350.49 on 2/16/16. The "cash on hand" form for Individual #2 dated, 2/16/16-3/1/16 read a balance of $150.28. A total of $200.21 was missing from Individual #2's account. There is no documentation for the $200.21 disbursement. The "cash on hand" form for Individual #3 dated, 1/20/16-2/16/16 read a balance of $724.48 on 2/16/16. The "cash on hand" form for Individual # 3 dated, 2/16/16-3/1/16 read a balance of $303.48 on 2/16/16. A total of $401.00 was missing from Individual #3's account on 2/16/16. There is no documentation for the $401.00 disbursement.The home shall keep an up-to-date financial and property record for each individual that includes the following (2) Disbursements made to or for the individual. Individual #3 balance on 2/16/16 in violation corrected to 323.48) (For each Individual, two ¿cash on hand¿ forms are used, Form #1 is used exclusively by the Residential Supervisor and Form #2 is used by Direct Care Staff.) Individual #1 was reimbursed via a check totaling 605.00 for the 60.00 disbursement, a 395.00 Form #1 discrepancy, and 150.00 on the ¿special purpose¿ form which was processed on 3/18/16 & deposited on 4/11/16. Individual #2 was reimbursed via a check totaling 200.21 which was processed on 3/18/16 & deposited on 4/11/16. Individual #3 was reimbursed via a check totaling 550.15 for the 401.00 disbursement & a 149.15 Form #1 discrepancy was processed on 3/18/16 & deposited on 4/11/16. To prevent this from being issue in the future, we will continue the process of having the House Supervisor perform random checks. We also have the House Supervisor review the entire form, and then it is reviewed by a member of the Residential Management Team before it is turned into & reviewed by our fiscal department. A member of the Residential Management Team will also perform monthly spot cash counts at our residential sites, in an attempt to prevent issues. [Within 60 days of receipt of the plan of correction, all staff responsible for implementing the procedures for the protection and adequate accounting of individual funds shall be trained by the CEO or designated fiscal department staff person in the policies and procedures to ensure an up-to-date financial record for each individual is maintained. Documentation of aforementioned checks and reviews and training shall be kept. (AS 7/8/16) 05/07/2016 Implemented
6400.22(e)(3)There were no receipts submitted for Individual #1's "special purpose form" dated 2/26/16 which documented the use of $150.00 to "buy the individual items." If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. o Violation was corrected by reimbursing Individual #1 the amount of 150.00 as part of a 605.00 check, which was the total of missing funds. The Residential Supervisor at that time withdrew 150.00 to ¿buy the individual items¿, but didn¿t purchase the items, provide receipts, or return the funds. To prevent this from being issue in the future, we will continue the process of having the House Supervisor perform random checks. We also have the House Supervisor review the entire form, and then it is reviewed by a member of the Residential Management Team before it is turned into & reviewed by our fiscal department. A member of the Residential Management Team will also perform monthly spot cash counts at our residential sites, in an attempt to prevent issues. [Within 60 days of receipt of the plan of correction, all staff responsible for implementing the procedures for the protection and adequate accounting of individual funds shall be trained by the CEO or designated fiscal department staff person in the policies and procedures to ensure an up-to-date financial record for each individual is maintained. Documentation of aforementioned checks and reviews and training shall be kept. (AS 7/8/16) 05/07/2016 Implemented
6400.33(f)Between the dates of 1/16/16 and 3/1/16 a total of $605.00 went missing from Individual # 1's account, $200.21 went missing from Individual #2's account and $550.15 form Individual #3's account.An individual has the right to receive, purchase, have and use personal property. o Violation was corrected by reimbursing Individual #1 the amount of 605.00, Individual #2 the amount of 200.21, and Individual # 3 the amount of 550.15. All three checks were processed on 3/18/16 and all three checks were deposited into the Individuals¿ respective accounts on 4/11/16. The amounts reimbursed for Individuals #1 and #3 were determined after finding funds missing on multiple tracking forms. To prevent this from being issue in the future, we will continue the process of having the House Supervisor perform random checks. We also have the House Supervisor review the entire form, and then it is reviewed by a member of the Residential Management Team before it is turned into & reviewed by our fiscal department. A member of the Residential Management Team will also perform monthly spot cash counts at our residential sites, in an attempt to prevent issues.[Within 60 days of receipt of the plan of correction, all staff responsible for implementing the procedures for the protection and adequate accounting of individual funds shall be trained by the CEO or designated fiscal department staff person in the policies and procedures to ensure an up-to-date financial record for each individual is maintained. Documentation of aforementioned checks and reviews and training shall be kept. (AS 7/8/16) 05/07/2016 Implemented
6400.141(c)(7)The two most recent gynecological examinations for Individual #3 were dated 9/18/15 and 8/8/14.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. o Individual #1 was seen by a gynecologist on 3/29/16. 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 to all House Supervisors or Managers, in case of need for emergency coverage. This ¿tickler¿ file is maintained by the House Supervisor & updated as new appointments are scheduled. [At least quarterly, the Program specialist shall review the tracking system to ensure completion and that physical examinations are competed within the required timeframes. Documentation of reviews shall be kept. (AS 7/8/16) 05/07/2016 Implemented
SIN-00053757 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 to get resigned by three individuals who reside at Sycamore 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
6400.106The two most recent furnace inspections were completed on 6/13/12 and then 8/1/13.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. 2. Furnace inspections will be completed within one year from 8/1/13 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-00042691 Renewal 09/17/2012 Compliant - Finalized