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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's Service Plan, last updated 7/21/25, explained that, "[Individual #1] needs all household supplies locked up as [they] [have] Prader Willi. These substances are only used with staff supervision. [Individual #1] needs monitored at all times due to this concern." In addition, Individual #1's current assessment, completed on 12/4/25, informed that, "Poisons are kept locked. [Individual #1] is only allowed to use cleaning products when supervised by staff." However, at 11:11 AM on 1/22/25, unlocked and accessible underneath the basement stairs were the following poisonous materials: 14 114 fluid-ounce cans of various paint and stains, including Olympic Maximum Stain and Sealant and Valspar Ultra Ceiling Paint. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All household supplies, paint, stains, sealant, and ceiling paint were removed from the service location basement closet underneath the steps. All items were taken back to our HQ where the Maintenance Department can proper store supplies. The location is now free of these potential poisons. |
01/30/2026
| Implemented |
| 6400.73(a) | At 11:08 AM on 1/22/26, the first set of three block steps leading to the home's front entry door did not have a handrail. The second set of four block steps leading to the home's front entry door also did not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The Maintenance Department installed a new exterior step railings at the service location entrance to mitigate a hazard risk. The railing was required for the initial three steps and the subsequent three steps leading to the front door. This work was carried out in extreme temperatures to ensure prompt regulatory compliance. |
02/04/2026
| Implemented |
| 6400.101 | At 10:55 AM on 1/22/26, the basement's interior door leading to the home's attached garage was equipped with a standard door lock assembly requiring a key disengage it from the garage side. The attached garage did not have an exterior swing door to prevent entrapment. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| While garage entrapment has not historically been a risk for staff or residents, steps have been taken to mitigate any perceived risk. Key access to the garage has been implemented, and training on its use was provided to both staff and residents at the service location. The garage, which already utilizes a motorized opener, key fob, and pin code access, now has a key available on both the interior and exterior to ensure that anyone can exit safely in the event of any entrapment. |
01/28/2026
| Implemented |
| 6400.104 | The home's Fire Department Notification Letter, dated 12/15/23, was not kept current, as it stated that "[Individual #1] is able to evacuate the building in under two minutes during a fire drill." However, Individual #1's Service Plan, last updated 7/21/25, explained that, "[Individual #1] needs verbally prompted and directed to evacuate in the event of a fire. [Individual #1] would panic easily and begin to cry without direction and support." Furthermore, Individual #1's current assessment, completed on 12/4/25, informed that, "[Individual #1] needs to be verbally prompted and directed to evacuate in the event of a fire." In addition, this Fire Department Notification Letter, dated 12/15/23, did not provide the exact location of Individual #1's bedroom, as it explained vaguely that, "[Individual #1's] bedroom is located on the second floor of the home" without including a description or diagram of the home's general layout. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| An internal audit of all local Fire Department Notification letters was conducted as of 1/23/2026 through 1/26/2026 which provided insight on the needs of the individuals as well as the location of bedrooms of individuals needing assistance. Clarity was provided in greater detail from the Fire Department letter on 12/15/2023 for Individual #1. A new local Fire Department Letter was provided to the Fire Department- with information on the site, bedroom location, and floorplan as of 1-26-2026. |
01/30/2026
| Implemented |
| 6400.151(a) | Direct Service Worker #1's date-of-hire is 9/10/25. Direct Service Worker #1's content of records included an initial and current physical examination, completed on 3/26/25, with a corresponding tuberculin skin test that was planted on 3/24/25 and read on 3/26/25 with negative results via Mantoux method. However, this physical examination and tuberculin skin test contained no identifying information relevant to Direct Service Worker #1, as the corresponding fields were left blank. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The initial physical for the staff member was completed prior to hire on 3/25/2026. The valid form was obtained from the individuals current employer, and documented on the physical form with the employee name and all relevant data points to make the employee eligible for hire. |
01/30/2026
| Implemented |
| 6400.32(r)(1) | At 11:04 AM on 1/22/26, Individual #1's bedroom door was equipped with standard door lock assembly requiring a key to operate it from the outside. However, agency interviews revealed that Individual #1 does not have their own key to lock and unlock their bedroom door and that only staff are in such possession of one. Individual #1's content of records---including their current assessment, completed on 12/4/25, and Service Plan, last updated 7/21/25---neither indicated Individual #1's choice not to have a key to their bedroom door, nor informed of any inability for Individual #1 to manage possession of such a key. At 11:05 AM, Individual #2's bedroom door was equipped with standard door lock assembly requiring a key to operate it from the outside. However, agency interviews revealed that Individual #2 does not have their own key to lock and unlock their bedroom door and that only staff are in such possession of one. Individual #2's content of records---including their current assessment, completed on 12/4/25, and Service Plan, last updated 7/31/25---neither indicated Individual #2's choice not to have a key to their bedroom door, nor informed of any inability for Individual #2 to manage possession of such a key. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | To address the use of locks and the need for keys for individual resident access and privacy, a one-on-one meeting was held with every Pathways Community Living resident to determine their desire for a door lock and/or key. Following this process, Individual #1 formally waived the right to have a key to the door. This decision was documented on 2-2-2026 by the staff member and Programs Administrator who conducted the meeting and gathered the information. Pathways Community Living will review the Key Access and Bedroom Lock agreement will be reviewed with every resident on an annual basis to provide access, freedom, choice, and control for the individual. |
02/02/2026
| Implemented |
| 6400.50(a) | Direct Service Worker #1's date-of-hire is 9/10/25. Direct Service Worker #1's orientation training did not document the trainer who had conducted the in-person courses completed on the following dates and required content topics: on 9/12/25 to 9/16/25---the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships; on 9/16/25---the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse; on 9/16/25---individual rights; and on 9/16/25---recognizing and reporting incidents. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The trainer that completed the New Hire Orientation was present during the inspection process, but did not have the training signature attached to the training records. All mandatory training for the individual at Pathways Community Living has been successfully completed, along with additional academic coursework in NADSP Frontline Supervisor Certification; which was provided during the review period. Documentation for all past training was provided to the appropriate trainer and, in this specific instance, the Human Resources Director confirmed completion. |
01/30/2026
| Implemented |
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