|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | During the inspection conducted 9/15/2023, there was a key lock on the garage door, which if engaged, could cause a potential blocked egress from the garage since there is no man door to exit outside. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 9/15/23, a maintenance request was submitted to correct this. The maintenance department changed the handle on the door on 9/18/23 to a handle that does not have a lock. The door remained unlocked from the discovery time on 9/15/23 until maintenance changed the handle on 9/18/23. |
09/18/2023
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(f) | The front door was the only evacuation route used during the fire drills held from 1/9/22 through 2/6/23. The home has two exit routes. | Alternate exit routes shall be used during fire drills. | Alternate routes will be utilized (front door and basement door exits). All staff will be trained on the purpose of utilizing alternate exits during fire drills, proper procedures for completing a fire drill and best practices in planning (for those responsible to ensure drills occur). |
05/15/2023
| Not Implemented |
| 6400.163(h) | Econazole Cream 1% Pro Re Nata medication, prescribed to Individual #1, expired 5/20/22. Polyeth Glycol Powder Pro Re Nata medication, prescribed to Individual #1, expired 1/8/22. Beisacodyl Pro Re Nata medication, prescribed to Individual #1, expired 12/29/20. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | All expired/discontinued medications were removed from the site and sent back to the Pharmacy. |
05/31/2023
| Not Implemented |
| 6400.165(g) | Individual #1 had a psychiatric medication review completed on 10/3/22 and then again on 3/6/23. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual # 1 was seen by her psychiatrist on 3/6/23, when Individual #1 missed her appointment on 12/29/23. |
05/15/2023
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(1) | Individual #1's assessment, completed 2/24/18, did not include functional strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | This information was updated 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)]186a and b [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)] |
03/23/2018
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 2/24/18, did not include likes, dislikes and interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | This information was updated 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.[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, 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)] |
03/23/2018
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 2/24/18, 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 information was updated 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)]186a and b [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)] |
03/23/2018
| Implemented |
| 6400.186(b) | The program specialist reviewed Individual #1's ISP end-dated 12/24/17 on 3/18/18. | 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)] |
04/04/2018
| Implemented |
|
|