Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244287 Renewal 05/07/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination, completed 6/29/23, did not include information pertinent diagnosis 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 3/18/2024 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 7/1/2024 with the PCP, site supervisor has been instructed to ensure all information is gathered and documented. 05/15/2024 Implemented
SIN-00225526 Renewal 06/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 12:32PM, the hot water temperature measured 131.3°F at the bathtub in the en-suite bathroom in the bedroom on the first floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. A plan has been set in place to continue monitoring the water temperatures on a weekly basis at all sites. As this location had not been occupied since December of 2022, the water temperature had a high reading on 6/5/2023. As of Wednesday, June 14, 2023, the water temperature at Montgomery House, 2765 St. Andrews Square, Apt. 1811, Allison Park, Pa. is in compliance. Maintenance came and adjusted the temperature on Monday, June 14, 2023, the water temperature at 10:30am was 115 degrees. Monitoring will continue with oversight of the Assistant Program Manager to ensure readings are recorded and corrected when applicable. 06/14/2023 Implemented
SIN-00208003 Renewal 07/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The security bar on the sliding glass door is an obstructed egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. In order to correct noncompliance in this area, the security bar on the sliding glass door will be removed. This item will be removed by agency personnel to ensure all things are removed properly. The security bar will not be utilized on the door in the future. [Verification of removal of security bar blocking egress received on 8/19/22 and reviewed on 8/31/22. DPOC by HDKP, HSLS, on 8/31/21]. 08/19/2022 Implemented
SIN-00136345 Renewal 06/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(12)The program specialist did not review the ISP reviews completed 9/30/18 and 3/31/18 with Individual #1.The program specialist shall be responsible for the following: Reviewing the ISP with the individual as required under § 6400.186. Retraining on the significant compliance measures for the ISP Review and the review with the participant. The document will be generated and approved by the Program Specialist; with the signature acknowledgment of the development of the ISP review. Any updates for the ISP have already been completed for this measure and will be entered accordingly to upcoming ISP Reviews effectively immediately. Retraining on this procedural change was discussed during supervision with the Program Specialist on 6/26/2018. The mentioned reviews were reviewed by the Program Specialist with the individual on 6/29/2018. 12 [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO shall audit a 25% sample of individual ISP review to ensure program specialist has reviewed the ISP revie3ws with the individual as required under 6400.186 (DPOC by AES,HSLS on 8/23/18)] 06/29/2018 Implemented
6400.68(b)On 6/7/18 at 9:18AM, the hot water temperatures measured 123.3°F in the bathtub in the bathroom adjacent to bedroom #1. Hot water temperatures in bathtubs and showers may not exceed 120°F. The temperature at leased buildings within Pathways Community Living presently have limited access to the hot water tank; as the building is a part of a large apartment complex. It will be the protocol of the residential sites to continue to monitor the water temperature on a weekly basis. Routinely, when the temperature presents with an above 120-degree Fahrenheit reading, staff will monitor the water temperatures twice daily until, the temperature is properly regulated. Spikes in the temperature can vary based on the logistics of the residential sites being in an apartment building. However, alerting maintenance of such a need can require extended wait times to modify the temperature. A water temperature gauge will be added to each bathroom shower to ensure a reading a of the water is taken prior to an individual getting into the shower or bath. This measure will ensure that residential staff are aware of the importance of tempering the water prior to participant use. Employees will receive documentation of the Water Temperature Back-Up plan during the upcoming staff meeting on 7/17/2018 and 7/20/2018. Actual temperature of the water at the specified site has been regulated since the time of the inspection. [On 7/30/18 the hot water temperature measured 107.4 at 12:14PM. Immediately, the CEO shall review the responsibilities of the positon as per 6400.43(b)(1)-(4) including compliance with this chapter and the 6400 regulations. Immediately, the CEO shall develop and implement policies and procedures to ensure the hot water temperature does not exceed 120°F at all times and train all staff persons on the aforementioned procedures. The policies and procedures shall include daily water temperature checks after the water temperature has been adjusted until the hot water temperature does not exceed 120°F for 14 consecutive days and then continuing at least weekly, immediate notification of the CEO if the hot water temperature measurement exceeds 120°F, documentation of the water temperature check and reviews of measurements at least monthly by the CEO. Documentation of the policies and procedures and trainings shall be kept. (DPOC by AES,HSLS on 8/29/18)] 07/08/2018 Implemented
6400.112(a)An unannounced fire drill was not held in September 2017. An unannounced fire drill shall be held at least once a month. The completion of fire drills remains important to the overall health and safety of the participants. A weekly review of fire drills and the necessity of accurate documentation of completion has been addressed with all residential site supervisors as of 6/27/2018. An all staff in service training will occur on both 7/17/2018 and 7/20/2018 to retrain on the importance of this matter. The fire drill in mention was completed yet documentation was not clear concerning the details of the drill. An extensive retraining on fire safety documentation standards was conducted by the Program Specialist in June 2018. Program Specialist will monitor that the proper documentation is provided by each site referencing a drill. The report will be sent to the CEO monthly as of July 2018. [Documentation of audits of fire drill record by the Program Specialist and the CEO shall be kept.(DPOC by AES,HSLS on 8/23/18)] 06/27/2018 Implemented
6400.112(c)The written fire drill record for the fire drill held on 7/19/17 did not indicate the amount of time it took for evacuation. This section was blank.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. Actual time of the fire drill was not circled on the sheet of the drill record. The document will be redesigned to provide clear indications of pertinent information that must be filled in on the form. An extensive training was conducted in review of this compliance measure on 6/27/2018. An all staff in service training will occur on both 7/17/2018 and 7/20/2018 to retrain on the importance of this matter. Program Specialist will monitor that the proper documentation is provided by each site referencing a drill. [At least quarterly, the CEO shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits of fire drill record by the Program Specialist and the CEO shall be kept.(DPOC by AES,HSLS on 8/23/18)] 06/27/2018 Implemented
6400.112(d)The fire drill held on 10/26/17 had an evacuation time of 3 minutes and 25 seconds. The fire drill held on 4/17/18 had an evacuation time of 2 minutes and 35 seconds. The home does not have a extended evacuation time in writing in the past year by a fire safety expert. (Repeated Violation-6/21/17, et al)Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.Fire drills which exceed 2 1/2 minutes must be redone and provided with an indication of what occurred to support a change in helping the participants evacuate in a significant amount of time. An all staff in service training will occur on both 7/17/2018 and 7/20/2018 to retrain on the importance of this matter. An extensive training was conducted in review of this compliance measure on 6/27/2018 with all residential site supervisors. Program Specialist will monitor that the proper documentation is provided by each site referencing a drill. [Fire drills conducted in July 2018 had evacuation times within 2 /12 minutes as required. At least quarterly, the CEO shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits of fire drill record by the Program Specialist and the CEO shall be kept.(DPOC by AES,HSLS on 8/23/18)] 06/27/2018 Implemented
6400.161(e)Lorazepam 0.5mg, take 1 tablet by mouth once as needed for anxiety prescribed for Individual #1 was reportedly discontinued 5/31/18 remained in the home.Discontinued prescription medications shall be disposed of in a safe manner.The identified prescription medication that was discontinued; was newly discontinued within the previous week. The noncompliance with the regulatory standard occurred for one week, being that it was present in the medication box. House Supervisors have been instructed to complete a weekly review of medication boxes to ensure appropriate medication is present for the participant. Medication administration recorders (MAR) are going to be crossed checked to the Medication blister packs and medication original labeled containers once a week by supervisors and the medication administration trainer. Also, during site inspections, the expiration dates of all medication will be checked. If any medication is expired it will be properly disposed of. A review of the medication will occur monthly by the Medication Trainer, with a report submitted to the Program Specialist based on findings. The Medication Trainer will be responsible for random checks of the medication boxes to be completed on a bi-weekly basis to improve quality control measures. The medication trainer was made aware of this procedural change as of 7/6/2018. [On 7/30/18, the Department viewed the discontinuation order dated 5/24/18 for Lorazepam .5mg: Take 1 tablet by mouth as needed for anxiety prescribed for Individual #1. The medication was present in the home. There were dates of 6/14/18, 6/15/18, 6/16/18 and initials on bubble pack. There were initials but no dates on 6 other bubbles that had been popped. Individual #1's June MAR did not document that the medication was administered. On 7/31/18, the Lorazepam was removed and disposed by the house supervisor and verified by the program coordinator on 8/3/18. Immediately, the CEO and a certified medication trainer shall educated all staff person responsible for the aforementioned auditing of medications in the policies and procedures for the safe disposal of discontinued and expired medication and the procedures for auditing all individuals medications, medication administration records (MARs) and physician's order to ensure medications are administered as prescribed, documented as required and discontinued and expired medications are disposed of in a safe manner. Documentation of the trainings shall be kept. At least weekly, a designate trained staff persons shall audit all individuals' medications, MARs and physicians orders to ensure medications are administered as prescribed, documented as required and discontinued and expired medications are disposed of in a safe manner. Documentation of the audits shall be kept and reviewed by the CEO at least monthly for 6 months and then continuing at least quarterly. (DPOC by AES,HSLS on 8/28/18)] 07/06/2018 Implemented
6400.186(a)The program specialist did not complete the ISP reviews completed 9/30/17 and 3/31/18 for Individual #1. The reviews were completed and signed by the residential supervisor.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The ISP review was historically completed by the House Supervisor, and then submitted for approval by the Program Specialist. The document will be generated and approved by the Program Specialist; with the signature acknowledgment of the development of the ISP review. Any updates for the ISP have already been completed for this measure and will be entered accordingly to upcoming ISP Reviews effectively immediately. Retraining on this procedural change was discussed during supervision with the Program Specialist on 6/26/2018. [The program specialist completed an ISP review ending on 6/30/18 which was signed by the program specialist and Individual #1 on 7/13/18. [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO shall audit a 25% sample of individual ISP reviews to ensure program specialist has completed the ISP reviews, timely. (DPOC by AES,HSLS on 8/23/18)] 06/26/2018 Implemented
SIN-00116135 Renewal 06/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(a)The program specialist completed ISP reviews for Individual #1 on 6-21-16 and then again on 10-21-16.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. In order to reduce reoccurrence of this issue, a plan has been set to review the ISP Review schedule for each participant on a monthly basis. The area of concern will require that the quarterly schedule for each participant is set for the FY 17/18 and ongoing. The review of the master schedule must occur monthly to ensure timely completion of the ISP Reviews. To ensure signature for the peer review, the House Supervisor must obtain this within 5 days of the report completion. Upon receipt of the signature, the proper mailing of the ISP Review can be sent to the identified Plan Team. [CEO shall complete review the tracking system to ensure competition of the ISP reviews for all individuals, timely. Documentation of reviews shall be kept. (AS 7/7/17)] 06/30/2017 Implemented
6400.186(b)Individual #1 did not sign the ISP review completed 6-21-16.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. A copy of the assessment was obtained. The specific document was reviewed and signed by the mentioned participant. The Program Specialist is aware of the documentation and will continue compliance in this area ongoing. A bi-monthly review of paperwork compliance areas will be based on the schedule determined by the Program Specialist for the FY 17/18. The Program Specialist was retrained in this area as of 6/30/2017. [Documentation of the bi-monthly reviews shall be kept. (AS 7/7/17)] 07/02/2017 Implemented
SIN-00097797 Renewal 05/31/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed by the agency between 2/24/16 and 2/26/16 was not fully completed.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. The licensing instrument was completed for the idenitified site. The compliance officer, Jason Garland Jr. is aware of the necessity of completing the licensing inspection instrument in full. The completion of the the form was discussed, and staff member was retrained on 6/14/2016. A face to face training was conducted on the appropriate way to utilize the form. In addition a review of the previous completed Inspection Instruments were reviewed to increase the level of understanding. As of 7/21/2016 an additional copy of the licensing instrument was provided for completion. During the week of July 25, 2016 a new instrument was completed for each residential site. The completed tools were then reviewed the immediate supervisor. Ongoing weekly site checks for compliance have been continuous, and will continue throughout the fiscal year. Jason Garland Jr. was retrained on this area and educated on the importance of the documents. There were no further issues regarding the document or the steps for completion. It was determined that the Compliance Officer will complete the document monthly. CEO will review the documents to for accurate completion. 08/06/2016 Implemented
6400.71The telephone number of the nearest ambulance was not on or by the telephone in the kitchen of the home. 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. Telephone numbers relevant to this regulation were posted and made visible to staff members at the identified site. Compliance Officer was retrained on the items that must be reviewed on the licensing inspection tool to remain in compliance. Compliance Officer was retrained by CEO during June 2016. Compliance Officer has made these changes and has ensured they were present at the residential site.[Immediately and at least quarterly, the CEO and/or compliance officers shall complete an onsite check of the all telephones in the community homes to ensure all required telephone numbers are on or by all telephone with an outside line. Documentation of all on site checks shall be kept.(AS 8/22/15)] 08/06/2016 Implemented
6400.151(c)(3)The physical examination dated 7/21/15 for Direct Service Worker #1 did not include a signed statement that the staff person is free of communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Program Specialist gathered documentation for the creation of a new form to include new hires to address if they are free on contagious disease. After the violation was determined a new form was created to address the area of concern. The identified employees were instructed to get a new physical to determine that they do not currently have a contagious disease. The administrative assistant has reviewed current employee files to remedy the issue. A review of records determined employees requiring this update to their file. The identified employees completed the given physicals to rectify the situation. A monthly review of employee files will occur going forward to identify documentation errors. The adminstrative assistant has been retrained by Program Specialist on this information as of June 2016, and August 2016. The adminstrative assistant has completed this and was retrained by the CEO. A monthly review of these documents will occur to ensure compliance. A copy of the updated physical has been completed, and updated in the employee file. Please see the attachements..[Prior to entering into staff record, designated management staff person will review staff physical examinations to ensure all required information is present. Documentation of reviews shall be kept. (AS 8/22/16)] 08/06/2016 Implemented
6400.186(e)The program specialist did not notify the plan team members including the family and the day program provider of the option to decline the ISP review documentation for Individual #1. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The paperwork has been mailed by the adminstrative assistant of Pathways Community Living to each participant family and treatment team providing the opportunity to decline the reciept of the ISP Quarterly Review, as of June 2016. At the time of August 2016, there have not been any declinations of the quarterly review, received to date by the agency. The letter to decline the Quarterly Review was drafted and completed by the Program Specialist, following retraining from the CEO post inspection. [The program specialist shall review all individuals' ISPs, invitation letters and other documentation to ensure the entire team is included in being notified of the option to decline. Documentation of correspondence of notifications shall be kept. (AS 8/22/16)] 08/06/2016 Implemented
SIN-00264833 Renewal 04/22/2025 Compliant - Finalized
SIN-00191170 Renewal 08/03/2021 Compliant - Finalized
SIN-00176286 Renewal 09/15/2020 Compliant - Finalized
SIN-00064539 Initial review 06/13/2014 Compliant - Finalized