Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00236469

Renewal

12/12/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	The self-assessment completed 8/28/2023, was not conducted within 3 to 6 months prior to the expiration date of the agency's certificate of compliance and did not include regulations 6400.42 to.6400.52c6; 6400.151a to 6400.152c, and 6400.166a1 to 6400.275. They 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.	The new Residential Director and the Clinical Manager will receive training on the self-assessment by the SVP of Program Operations by 1/5/24. A new self-assessment, including completing them fully, will be completed for all homes by the Residential Director and/or Clinical Team by 1/31/24.	01/31/2024	Implemented

SIN-00227739

Unannounced Monitoring

07/14/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.72(a)	On 7/14/2023, Individual #1's bedroom window did not contain a screen.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	During an internal audit, it was discovered that the screen was damaged. Maintenance had attempted to repair it, but were unable to. The screen needed to be special ordered due to the way it locked into the window frame. The Fleet and Facilities Director indicated it had been ordered on 7/14/23. Order confirmation was provided to the Senior VP of Operations on 7/18/23 with verbal confirmation that it would take approximately 4 weeks to arrive. We will be happy to provide confirmation when the screen is received and installed.	08/02/2023	Implemented
6400.105	On 7/14/2023, the dryer vent was full with lint causing a potential fire hazard.	Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.	The lint was removed from the dryer vent on 7/14/23 at the time of the finding.	08/02/2023	Implemented
6400.112(d)	The fire drill conducted 4/04/2023 had an evacuation time of 2 minutes, 40 seconds.	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 employe 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.	The evacuation time for the April fire drill had been identified internally and the Home Coordinator was retrained on 6/21/23. On 7/25/23, all Home Coordinators were trained on fire drill requirements, the required exit time, and what to do if the evacuation time is over the allowable time.	08/07/2023	Implemented
6400.144	Individual #1 is prescribed Senna 8.6mg tablet with instructions to take 2 tablets by mouth at bedtime until regular bowel movement is every day or every other day, then use as needed. Staff did not document if the individual did or did not have a bowel movement from 7/07/2023 through 7/11/2023.	Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.	All bowel movement charts were updated to add times of BMs and to document if no BM rather than leaving blank as well as working with the day program to document. EIM reports (#9249512 & 9248854) were entered for Medication Error and Neglect - Failure to Provide Medication Management were entered.	08/02/2023	Implemented
6400.165(c)	Individual #1 is prescribed Senna Tab 8.6mg with instructions to take 2 tablets by mouth at bedtime until regular bowel movement is every day or every other day, then use as needed. The individual is documented as having regular bowel movements for the following dates: 7/01/2023 through 7/06/2023, 7/12/2023 through 7/14/2023. The medication was administered at 8:00pm on 7/03/2023 through 7/08/2023 and 7/11/2023 through 7/13/2023.	A prescription medication shall be administered as prescribed.	On 8/2/23, all bowel movement charts were updated to include the time of the bowel movement so it can be identified if the bowel movement occurred after the medication was administered, showing the desired effect or if it occurred prior to, resulting in a medication error. The Program Director interviewed staff to determine that the bowel movements occurred after the administration of the medication, indicating the desired effect occurred and not a medication error.	08/02/2023	Implemented
6400.166(a)(13)	Individual #1's July 2023 medication administration record did not include name and initials of the person who administered the following medications: Align Probiotic Gummie at 8:00am on 7/04/2023 & 7/07/2023 and 8:00pm on 7/06/2023, Caltrate =D3 600-800 tablet at 8:00am on 7/04/2023, Megestrol AC 20mg tablet at 8:00am on 7/04/2023, Polyethylene Glycol Powder 3350 NF at 8:00am on 7/04/2023, Tolterodine 4mg ER Capsule at 8:00am on 7/04/2023, Ammonium Lac Lotion 12% at 8:00am on 7/01/2023, 7/02/2023, & 7/04/2023, Clotrim/Beta Cream Diprop, at 8:00am on 7/01/2023, 7/02/2023, & 7/04/2023. Individual #2's July 2023 medication administration record did not include name and initials of the person who administered the following medications: Acetaminophen 500mg Tablet 8:00am on 7/04/2023, Allergy Relief 180mg Tablet 8:00am on 7/04/2023, Artificial Sol Tears 8:00am on 7/04/2023 and 12:00pm on 7/04/2023, 7/07/2023, and 7/13/2023, Aspirin 81mg Chew 8:00am on 7/04/2023, Atorvastatin 20mg tablet 8:00am on 7/04/2023, Chlorhex Glucose Sol 0.12% 8:00am on 7/04/2023 and 7/13/2023, Divalproex 125mg Capsule 8am on 7/04/2023, Fiber Laxative 625mg tablet 8:00am on 7/04/2023, Ipratropium Spray 0.03% 8:00am on 7/04/2023, Lisinopril 5mg tablet 8:00am on 7/04/2023, Mag Oxide 400mg tablet 8:00am on 7/04/2023, Metformin 1000mg tablet 8:00am on 7/04/2023, Polyethylene Glycol Powder 3350 NF 8:00am on 7/04/2023, Refresh Gel Optive 10:00pm on 7/06/2023, 7/07/2023, 7/10/2023, and 7/13/2023, Sertraline 100mg tablet 8:00am on 7/04/2023, Triamt/HCTZ 37.5-25 tablet 8:00am on 7/04/2023, and Vitamin C 500mg tablet 8:00am on 7/04/2023 (Repeated violation-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.	An immediate review and interviews with staff were completed by the Program Director that verified the medications were administered as prescribed, but not documented on as required and staff were reminded of documentation requirements, even while taking the individuals on vacation.	08/02/2023	Implemented
6400.166(a)(15)	Individual #1 is prescribed Clonazepam 1mg tablet with instructions to take 1 tablet by mouth at bedtime for anxiety and may crush and put in applesauce. On 7/14/2023 there was a sticker from the pharmacy on the medication bottle stating to swallow whole with a drink of water.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable.	The prescribing doctor was contacted on 7/17/23 and when they called back, it was confirmed that the medication could be crushed and taken with applesauce. The sticker (which was not part of the label) stating to swallow whole with water was removed.	08/02/2023	Implemented
6400.167(a)(1)	Individual #1 is prescribed Align Probiotic Gummies with instructions to chew 1 gummy by mouth twice a day for supplement. Individual #1's July 2023 medication administration record documents the following notes from 7/07/2023 at 8:00pm through 7/11/2023 at 8:00am: "physically unable to take" or "unavailable to give". Individual #2 is prescribed Chlorhex Glucose Solution 0.12% with instructions after breakfast and brushing, swish and spit 10ml by mouth twice a day for oral care. Individual #2's last documented administration of the medication was 8:00pm on 7/07/2023. Individual #2's July 2023 medication administration record documents the following notes from 7/08/2023 at 8:00am through 7/14/2023 at 8:00am: "physically unable to take" or "unavailable to give". Individual #2 is prescribed Polyethlene Glycol Powder 3350 NF with instructions to dissolve 1 capful (17gm) in 8oz of water and take by mouth daily. Direct Service Worker #1 stated she administered the last dose on 7/13/2023 at 8:00pm and discarded the bottle after because she used the last of the medication. Individual #1 had not received a refill for the medication and was unable to have had her 8:00am dose on 7/14/2023 administered (Repeated Violation-5/18/2023).	Medication errors include the following: Failure to administer a medication.	After a review and interview with staff, the Program Director determined the Align Probiotic Gummies were administered as prescribed, but not documented. The staff members were reminded to utilize the scanner to ensure all medications are administered. The PCP was contacted on 7/17/23 to renew the prescription for the Chlorehexidine which was finally done and then delivered on 7/27/23. The Polyethlene Glycol powder was reordered on 7/14/23 and delivered to the home.	08/02/2023	Implemented

SIN-00225273

Unannounced Monitoring

05/18/2023

Non Compliant - Finalized

SIN-00203875

Renewal

04/21/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.22(e)(1)	Individual #1's April 2022 financial record showed a discrepancy of $100.00 missing from the individuals' funds. There was a note that $100.00 was given to Direct Service Worker #1 on 3/30/2022 to take Individual #1 shopping. There was no receipt onsite during the inspection on 4/22/2022. House Supervisor #2 contacted Direct Support Staff #1 who indicated that she had a receipt from Walmart for $58.25 and Individual #1's change at her home.	If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals.	The change ($41.75) from the purchase was returned to the special purpose form on 4/22/22. The residential director updated the petty cash procedure to reflect that when a purchase occurs the receipt and any change need to be deposited back to book 2 the same day. All residential staff were sent an email with the updated procedure on 5/23/22.	05/23/2022	Implemented
6400.22(e)(3)	Individual #1's April 2022 financial record showed a discrepancy of $100.00 missing from the individuals' funds. There was a note that $100.00 was given to Direct Service Worker #1 on 3/30/2022 to take Individual #1 shopping. There was no receipt onsite during the inspection on 4/22/2022. House Supervisor #2 contacted Direct Support Staff #1 who indicated that she had a receipt from Walmart for $58.25 and Individual #1's change at her home.	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.	The receipt from the purchase was returned to the special purpose form on 4/22/22. The residential director updated the petty cash procedure to reflect that when a purchase occurs the receipt and any change need to be deposited back to book 2 the same day. All residential staff were sent an email with the updated procedure on 5/23/22.	05/23/2022	Implemented
6400.111(f)	During the inspection conducted on 4/22/2022, there was a fire extinguisher identified in the laundry room next to the kitchen that was last inspected in March 2021.	A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.	On 4/27/22 the fire extinguisher was inspected, and a new tag was placed on it. The maintenance director oversees the completion of the annual fire extinguisher inspections.	04/27/2022	Implemented
6400.181(e)(12)	Individual #1's 2/05/22 assessment did not include recommendations for specific areas of training, programming and services. This section was left blank.	The assessment must include the following information: Recommendations for specific areas of training, programming and services.	On 4/22/22 the Clinical Specialist added recommendations for specific areas of training, programming, and services to the assessment. The Clinical Specialist is responsible for completing the initial and annual assessments with all sections being fully filled out.	04/22/2022	Implemented
6400.166(a)(13)	Individual #1 is prescribed Acetamin 500mg tablet: Take two tablets by mouth twice a day for chronic pain. Individual #1's April 2022 Medication Administration Record was not initialed for the 4/12/2022 8pm administration. Individual #1 is prescribed Clonazepam 1mg tablet: Take 1 tablet by mouth at bedtime for anxiety. Individual #1's April 2022 Medication Administration Record was not initialed for the 4/12/2022 8pm administration.	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.	The documentation error was corrected on 4/22/22.	04/22/2022	Implemented

SIN-00172275

Renewal

03/04/2020

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	The self-assessment, dated 8/21/19, was not completed in the following areas: Staffing, Staff Health, 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-00110818

Renewal

03/22/2017

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	The home's self-assessment was completed on 12-7-16. The agency's certificate of compliance 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-00053756

Renewal

01/21/2014

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC 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 four individuals who reside at Linn 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
6400.106	The two most recent furnace inspections were completed on 4/5/12 and then 4/29/13.	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 4/29/13 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-00257321

Renewal

12/11/2024

Compliant - Finalized

SIN-00231210

Unannounced Monitoring

09/15/2023

Compliant - Finalized

SIN-00091067

Renewal

03/03/2016

Compliant - Finalized

SIN-00042690

Renewal

09/17/2012

Compliant - Finalized