Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00203878 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)On 4/22/22 at 10:03 am, the accessible attic was observed without a smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The attic is always screwed shut so no access is available to staff or the individual. The homeowner had gone in the attic and forgot to put the screws back in. On 4/22/22 a smoke detector and fire extinguisher were placed in the attic as a precautionary measure and the screws were put back in. 04/22/2022 Implemented
6400.111(a)On 4/22/22 at 10:03 am, the accessible attic was observed without a fire extinguisher.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The attic is always screwed shut so no access is available to staff or the individual. The homeowner had gone in the attic and forgot to put the screws back in. On 4/22/22 a smoke detector and fire extinguisher were placed in the attic as a precautionary measure and the screws were put back in. 04/22/2022 Implemented
SIN-00172278 Renewal 03/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment, dated 8/21/19, was not completed in the following areas: General Requirements, Staffing, Staff Health, Provider Services, Day Services, 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-00110821 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 12-10-16 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
6400.186(d)The program specialist did not provide the ISP review documentation ending on 10-28-16 completed for Individual #1 to the plan team members. The program specialist provided the ISP review documentation ending on 4/28/16 completed for Individual #1 to the plan team members on 11-10-16.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
SIN-00101408 Unannounced Monitoring 08/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(a)The fire extinguisher in the basement of the home had a 1-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The basement fire extinguisher was replaced with a properly rated 2-A fire extinguisher on 08/15/2016. Our maintenance department has been notified to ensure that any future fire extinguishers placed within our homes must meet regulation standards. [Immediately and at least monthly all fire extinguishers in all homes will be checked by maintenance department or designated staff person to ensure there is at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic in all homes. (AS 1/25/17)] 10/14/2016 Implemented
SIN-00091070 Renewal 03/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)A video camera located in Individual #1's bedroom was being used to monitor Individual #1.An individual has the right to privacy in bedrooms, bathrooms and during personal care. o We will be correcting the violation by filing a request for waiver of regulation, which will include a letter of explanation from the legal guardian (mother). The camera located in Individual #1¿s bedroom was already in operation when we assumed control of operations at this location, as it was put into use by the individuals¿ legal guardian. Expected date of correction is 4/30/16.* Correction to expected date of correction: there was a delay in receiving the letter from the legal guardian. New expected date of correction is 5/13/16.If wavier request is denied and the camera had to be removed, we believe the mother would strongly consider removing him from our program and not consider any program which wouldn¿t or couldn¿t accommodate their wishes. [The camera was removed from Individual #1's bedroom. (AS 3/23/17)] 05/07/2016 Implemented
6400.110(f)Individual #1's diagnoses include severe sensory neutral hearing loss. Individual #1 is not able to hear the fire alarm system. On 3/4/17, at approximately 11:45, the fire alarm system was tested and the bed shaker on Individual #1's bed was not operable. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. (Date of fire alarm test in violation corrected to 3/4/16) Violation was corrected by immediately ordering a new bed shaker, via an online retailer, on 3/4/16. The unit was delivered and installed on 3/10/16by the House Supervisor. The unit was immediately tested and was working perfectly. Also, we have added a monthly check of related adaptive equipment to our fire drill forms for our two locations in which a hearing impaired individual resides. Fire drills are performed by the House Supervisor monthly; on random days, at random times. The fire drill forms are them reviewed by a member of the Residential Management Team. [CEO will develop, implement and train house supervisors and residential management team on policy and procedures for testing and repair of bed shakers and other adaptive equipment to ensure individuals with hearing impairment will be alerted in the event of a fire. Documentation of the reviews of the bed shakers and other adaptive equipment testing shall be kept to ensure completion of regular testing and that individuals with hearing impairments are alerted in the event of a fire. (AS 5/19/16)] 05/07/2016 Implemented
SIN-00053759 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 one individual who resides at Lantz 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
SIN-00051703 Initial review 07/17/2013 Compliant - Finalized