Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244290 Renewal 05/07/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)Individual #2's physical examination, completed 5/19/23, did not address health maintenance needs. This section was of the form was blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. In this instance the physical examination form was provided to us at intake on or before 6/17/2023 as a new admission. In this case we will institute a policy modification that all new admissions to Pathways Community Living will include the use of the agency generated form to ensure all aspects of this regulation is completed. Next physical is scheduled for 5/24/2024 with the PCP, site supervisor will be instructed to ensure all information is gathered and documented. 05/15/2024 Implemented
6400.141(c)(12)Individual #2's physical examination, completed 5/19/23, did not address physical limitations. This section of the form was blank.The physical examination shall include: Physical limitations of the individual. In this instance the physical examination form was provided to us at intake on or before 6/17/2023 as a new admission. In this case we will institute a policy modification that all new admissions to Pathways Community Living will include the use of the agency generated form to ensure all aspects of this regulation is completed. Next physical is scheduled for 5/24/2024 with the PCP, site supervisor has been instructed to ensure all information is gathered and documented. 05/15/2024 Implemented
6400.141(c)(14)Individual #2's physical examination, completed 5/99/23, did not address information pertinent to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. In this instance, the physical examination form was provided to us at intake on or before 6/17/2023 as a new admission. In this case we will institute a policy modification that all new admissions to Pathways Community Living will include the use of the agency generated form to ensure all aspects of this regulation is completed. Next physical is scheduled for 5/24/2024 with the PCP, site supervisor has been instructed to ensure all information is gathered and documented. 05/15/2024 Implemented
SIN-00191174 Renewal 08/03/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(a)The only fire extinguisher located on the basement level of the home had a 1A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. A plan has been set in place that monthly, a review of all fire extinguishers will occur. At the time of the fire drill, the information regarding the expiration of the fire extinguisher will be done by the site supervisor. Program Specialist will ensure that the monthly review of fire drills captures this information. To maintain compliance two new Fire Extinguishers with a 2-A rating have been added to the residential site to maintain compliance with the regulation. 08/16/2021 Implemented
6400.111(c)The only fire extinguisher located in the kitchen of the home had a 1A rating. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). A plan has been set in place that monthly, a review of all fire extinguishers will occur. At the time of the fire drill, the information regarding the expiration of the fire extinguisher will be done by the site supervisor. Program Specialist will ensure that the monthly review of fire drills captures this information. 08/16/2021 Implemented
6400.166(a)(11)Individual #1's August 2021 medication administration record did not include: Diagnosis or purpose for any of the medication.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.Agency nurse received the updated medication cards for the participant from the agency contracted PDC Pharmacy on 8/16/21. A meeting was held via telephone with the pharmacy to adjust the error in missing purpose of medication info. The data was updated on the medication administration record. A review of all participants medication purpose was completed during the week of 8/16/2021. For August, the new medication cycle EMAR reflecting these changes with medication reasons is current. 08/16/2021 Implemented
SIN-00208006 Renewal 07/12/2022 Compliant - Finalized