Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236468 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed 8/01/2023, 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 6400.182a to 6400.209. 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, including the timeframe required to complete, by the SVP of Program Operations by 1/5/24. A new self-assessment will be completed for all homes by the Residential Director and/or Clinical Team by 1/31/24. 01/31/2024 Implemented
6400.141(c)(9)Individual #1, date of birth 11/11/1955, had a prostate examination completed 5/03/2022 and then again 7/14/2023.The physical examination shall include: A prostate examination for men 40 years of age or older. As soon as it was identified that this appointment was not completed timely, it was scheduled and completed. 01/05/2024 Implemented
SIN-00231212 Unannounced Monitoring 09/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)During the inspection conducted 9/15/2023 the hot water temperature measured 123.4°F at 1:36pm at the kitchen sink.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. On 9/15/23, the Home Coordinator adjusted the water temperature and it later tested at 117. Maintenance adjusted the scald guard on 9/18/23 and the water tested at 116 degrees. The water temperature will be checked daily until it is consistently seen as being under 120 degrees. 10/31/2023 Implemented
6400.165(c)During the inspection conducted 9/15/2023, Individual #1 is prescribed Peg 3350 Powder, with instructions to mix 17 grams in 8oz. water and take by mouth twice daily for 3 days, until bowel movement occurs. Individual #1's September 2023 medication administration record documents the medication was administered at 8:00am and 8:00pm beginning on 9/02/2023 through 8:00am on 9/15/2023. Individual #1's September 2023 bowel movement chart documents the individual had bowel movements on the following dates: 9/01/2023, 9/02/2023, 9/03/2023, 9/08/2023, 9/09/2023, 9/10/2023, and 9/13/2023.A prescription medication shall be administered as prescribed.On 9/15/23, the Director of Community Health contacted the hospice nurse to confirm the order and have them fax it over in writing. The second page of the order did indicate the PRN portion of the order, so the MAR was immediately updated and staff notified. EIM 9282729 (Neglect/Failure to Provide Medication Management) and 9282723 (Med Error) were both entered into the EIM system. 09/15/2023 Implemented
6400.166(a)(11)During the inspection conducted 9/15/2023, Individual #1's September 2023 medication administration record did not include the diagnosis or purpose for the Risperidone .5mg.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.On 9/15/23, the Home Coordinator and Adult Services Trainer updated the MAR to reflect the diagnosis/purpose. 10/04/2023 Implemented
SIN-00221691 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination completed on 8/12/21 and then again 1/26/23.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Upon identification of late physical examination, an appointment was scheduled and completed on 1/26/23. 05/15/2023 Implemented
SIN-00186619 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(c)Individual #1 assessment completed on 10/15/20, states that the individual does not avoid heat sources. Current ISP with an annual review update date of 1/29/21, states that Individual #1 recognizes and avoids heat sources and knows the potential dangers.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 4/22/21 the Clinical Specialist emailed the SC to make the correction in the ISP. The Clinical Specialist is responsible for completing the annual assessments prior to the ISP meetings. In the ISP meeting the Clinical Specialist will ensure all the information is accurate in the ISP. Once we receive the finalized ISP, the Clinical Specialist will review for accuracy. If something is not correct, the Clinical Specialist will email the SC to make the change. 04/22/2021 Implemented
SIN-00131719 Renewal 03/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was not an unannounced fire drill held in March 2017. An unannounced fire drill shall be held at least once a month. This was identified in May 2017. In June 2017 PathWays Residential Program implemented a new fire drill procedure. A yearly fire drill schedule was implemented. The supervisors are the only ones who receive the schedule to ensure they remain unannounced. Once the fire drill is completed, the supervisor faxes a copy to the office where it is stored in a master fire drill binder. The binder is reviewed monthly by the assistant director.[Within 30 days of receipt of the plan of correction, a designated management staff person shall educate all staff persons responsible for conducting and documenting and reviewing fire drills and fire drill records of the requirements as per 6400.112(a)-(I). Documentation of the trainings shall be kept. Upon completion of fire drills, a designated management staff person shall audit the fire drill records to ensure all fire drills are conducted and documented as required. Documentation of the audits shall be kept. (AS 4/6/18)] 06/01/2017 Implemented
6400.141(c)(9)The physical examination, completed on 8/25/16, for Individual #1, date of birth 11/11/55 deferred the prostate examination to the urologist. On 2/23/17, Individual #1 refused to have the prostate examination completed at which time the urologist ordered the PSA. Individual #1 did not have the PSA completed.The physical examination shall include: A prostate examination for men 40 years of age or older. An appointment was scheduled for 4/10/18. The residential supervisor is responsible for scheduling and completely all appointments and follow-up appointments. They are to put these appointments on their outlook calendars and set reminders when needed. Starting May 2018, PathWays Residential Program will be implementing internal quarterly audits to ensure compliance. [Within 30 days of receipt of the plan of correction, the residential director shall train the residential supervisors of their responsibilities and the procedures to ensure all individuals have physical examinations completed timely with all required information as per 6400.141(c)(1)-(15) and that required areas are not to be left blank. Documentation of the trainings shall be kept. Within 60 days of receipt of the plan of correction and upon completion, the residential supervisor(s) shall audit all individuals' current physical examinations to ensure all required information is completed and there are not any required areas left blank and individuals health services are provided. Missing information shall immediately be obtained. At least quarterly for 1 year, a designated management staff person shall audit a 10% sample of individuals' current physical examination to ensure timely completion with all required information and individual health services are being provided. Documentation of all audits shall be kept. (AS 4/6/18)] 04/10/2018 Implemented
6400.181(a)Individual #1 had an assessment completed on 7/7/16 and then again on 10/4/17. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. This is tracked through the use of the ¿Rolling Program Specialist Chart¿. The ¿Rolling PS Chart¿ includes each client, each quarterly review period, and the date of the annual assessment. The ¿Rolling PS Chart¿ is updated by the Program Specialist upon completion of each quarterly and/or assessment. This chart is located on the server and will be reviewed by the Assistant Director and/or Director during internal quarterly audits for the upcoming period. [Within 30 days of receipt of the plan of correction, designated management staff person shall educate the program specialist(s), assistant director(s) and director on the aforementioned procedures to ensure timely completion of assessments. Documentation of trainings shall be kept. Documentation of aforementioned quarterly audits shall be kept. (AS 4/6/18)] 10/04/2017 Implemented
6400.181(d)Individual #1's assessment, completed 10/4/17, was not signed by a program specialist.The program specialist shall sign and date the assessment. The program specialist will complete and sign all assessments. Once an assessment is fully completed and signed by the PS, the assistant director and/or director will review. After the assessment has been reviewed by the RAD/RPD, it will be presented to the individual. [Immediately, the program specialist shall sign and date Individual #1's assessment, completed 2/13/18. Within 30 days of receipt of the plan of correction, the program specialist and a designated management staff person shall review all individuals' assessments to ensure the program specialist has signed and dated all individuals' current assessments. Within 60 days of receipt of the plan of correction, aforementioned review process by the director(s) shall be completed. Documentation of aforementioned reviews by the director(s) shall be kept. (AS 4/6/18)] 04/04/2018 Implemented
6400.181(e)(12)Individual #1's assessment, completed 10/4/17, did not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. This was added on 3/23/18. The program specialist will complete and sign all assessments. Once an assessment is fully completed and signed by the PS, the assistant director and/or director will review. After the assessment has been reviewed by the RAD/RPD, it will be presented to the individual. [Immediately, a designated management staff person shall educate the program specialist(s) as to the required information in individuals' assessments as per 181(e)(1)-(14). Documentation of the training shall be kept. Within 30 days of receipt of the plan of correction, the program specialist shall review all individuals' assessments to ensure all required information is included. Within 60 days of receipt of the plan of correction, the assistant director(s) and/or director(s) audit all individuals' assessments to ensure all required information is included. Documentation of reviews by the assistant director(s) and/or director(s) shall be kept. (AS 4/6/18)] 03/23/2018 Implemented
6400.186(a)The program specialist completed Individual #1's ISP review on 8/1/17 and then again on 3/12/18. Individual #1's ISP review for 8/1/17 through 10/31/17 reviewed the services and expected outcomes for 5/2/17 through 7/31/17.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. As of March 21, 2018 the 8/1/17 through 10/31/17 quarterly review was updated with the correct information and signed by the individual. Pathways Residential Program has the Program Specialist complete all quarterly reviews with the data supplied during the specified time frame. The PS will check the information. Then, the Residential Director will conduct a second check of the information and then sign the review. Once this takes place, the quarterly review will be presented to the individual. [Immediately, the residential director shall develop and implement a tracking system to ensure the program specialist and individual review the ISP reviews, timely. Within 30 days of receipt of the plan of correction, designated management staff person shall educate the program specialist(s) on the aforementioned procedures to ensure timely completion of reviews of the ISP reviews. Documentation of trainings shall be kept. (AS 4/6/18)] 03/21/2018 Implemented
6400.186(b)Individual #1's ISP review end-dated 10/31/17 was signed by the program specialist and individual on 8/1/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Pathways Residential Program has the Program Specialist complete all quarterly reviews with the data supplied during the specified time frame. The PS will check the information. Then, the Residential Director will conduct a second check of the information and then sign the review. Once this takes place, the quarterly review will be presented to the individual. [Immediately, the residential director shall develop and implement a tracking system to ensure the program specialist and individual review and sign and date the ISP reviews, timely. Within 30 days of receipt of the plan of correction, designated management staff person shall educate the program specialist(s) on the aforementioned procedures to ensure timely completion of reviews of the ISP reviews. Documentation of trainings shall be kept. (AS 4/6/18)] 03/21/2018 Implemented
SIN-00053755 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 four individuals who reside at Hewitt 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
6400.106The two most recent furnace inspections were completed on 5/1/13 and 11/21/11.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. Furnace inspections will be completed within one year from 5/1/13 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-00042689 Renewal 09/17/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)The preadmission physical examination dated July 2, 2012 for Individual #1 does not include a vision and hearing screenig. Fully Implemented - PE - 2-14-13(4) Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. With any future admissions we will provide a copy of our own Physical document that addresses all areas of compliance needed per 6400 Regulations, to be completed in its entirety by the client¿s current Primary Care Physician or other licensed Physician that is providing medical advice for the client. This document will be reviewed by the Residential Program Supervisor, Residential Program Specialist, Residential Program Manager, and/or Residential Program Director prior to admission to ensure all areas of compliance are met. 11/19/2012 Implemented
6400.141(c)(9)The preadmission physical examination dated July 2, 2012 for Individual # 1 does not include a prostate examination. Full Implemented - PE -2-14-13(9) A prostate examination for men 40 years of age or older. With any future admissions we will provide a copy of our own Physical document that addresses all areas of compliance needed per 6400 Regulations, to be completed in its entirety by the client¿s current Primary Care Physician or other licensed Physician that is providing medical advice for the client. This document will be reviewed by the Residential Program Supervisor, Residential Program Specialist, Residential Program Manager, and/or Residential Program Director prior to admission to ensure all areas of compliance are met. 11/19/2012 Implemented
6400.141(c)(14)The preadmission physical examination dated July 2, 2012 for Individual # 1 does not include emergency information. Fully Implemented - PE - 2-14-13(14) Medical information pertinent to diagnosis and treatment in case of an emergency. With any future admissions we will provide a copy of our own Physical document that addresses all areas of compliance needed per 6400 Regulations, to be completed in its entirety by the client¿s current Primary Care Physician or other licensed Physician that is providing medical advice for the client. This document will be reviewed by the Residential Program Supervisor, Residential Program Specialist, Residential Program Manager, and/or Residential Program Director prior to admission to ensure all areas of compliance are met. 11/19/2012 Implemented
SIN-00151725 Renewal 03/12/2019 Compliant - Finalized
SIN-00075639 Renewal 02/13/2015 Compliant - Finalized