Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258286 Renewal 01/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)(4)On 1/8/25, Individual #1's bedroom door was equipped with a privacy door lock assembly with a thumbnail, straight-edge access mechanism on the exterior and a turn latch on the interior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.Individual #1's bedroom door lock was changed by the maintenance department, to a pass through style door knob with no locking mechanism on 1/8/2025. An assessment was completed on 1/16/25 by the Program Specialist to determine: the individual's expressed desire to have a lock, needs, and abilities to operate a specific type of lock. All staff working with the individual will be trained on this updated assessment & ISP upon update, and an ISP update request will be made, to include this updated information. 01/16/2025 Implemented
6400.44(c)(3)Program Specialist #1's, date of hire 6/11/24, did not meet the educational requirements as they only acquired a high school diploma.A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism.Program Specialist #1 was removed from all Program Specialist duties, on 1/7/2025. The agency¿s required credentials for a Program Specialist have been changed on 1/8/2025,to include an associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism. 01/08/2025 Implemented
SIN-00217955 Renewal 01/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace inspections and cleanings completed 9/9/21 & 9/6/22 were not completed by a professional furnace cleaning company.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. Lifeway Services immediately will use a Professional Furnace Cleaning company to perform a cleaning & inspection of each furnace within the service locations, at least once a year. This cleaning & inspection will be recorded on the Heating, Ventilation, and Air Conditioning (HVAC) company¿s provided Furnace Cleaning & Maintenance Report, and will be filed and recorded by the agency¿s standards & compliance department. Immediate remediation includes an engagement agreement between Lifeway Services, LLC and a local furnace company (executed on 2/2/2023, which details that all site¿s cleanings & inspections will occur annually. These initial cleanings & inspections will be performed between the dates of 2/7/23 and 2/15/2023 02/03/2023 Implemented
SIN-00148709 Renewal 01/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for fire drills held on 1/4/18 and 6/5/18 did not include the exact time, AM or PM was missing.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. Plan of Correction 6400.112(c) The written fire drill records for fire drills held on 1/4/18 and 6/5/18 did not include the exact time, AM or PM was missing. What specific change will be made: A new electronic Fire Drill form has been developed to ensure completion of deficits reported A Compliance Department and Compliance Team was developed to ensure oversight and compliance. Who will make the change: Compliance Department, Compliance Team (composed of Compliance Department representative, Program Specialist, Administration, and Training Department, Training Department, and DSP. When will the change be made: 2/1/19 How will the change be made: An electronic Fire Drill form has been developed that requires every question to be completed, including: The date the drill occurs The exact time the Fire Drill begins and ends: (a.m. and/or p.m. must be selected before this section can be completed) Exit route used Any problems encountered during drill Operational status of smoke detectors In the event that the electronic record is not available, a paper Fire Drill record with a checklist prompting specifics listed above as well as other relevant factors will be used. All agency fire drill records will be reviewed by the Compliance Department weekly for: Timeliness and completion, including; Exact time Hour Minutes Seconds If drill occurred during a.m. or p.m. If an alternative route can be/was used The Compliance Team will meet monthly to review the Fire Drill forms/process and to ensure randomness occurs across all areas of the Fire Drill process. What system have you implemented to make sure that the same violation will not occur again: Electronic Fire Drill Form Compliance Department oversight Compliance Team reviews What training has been provided to your staff: The Compliance has reviewed regulation requirements, deficits, and developed corrective action plans The Training and Compliance Departments have been instructed of required processes. DCP training is being rolled out agency-wide beginning February 1, 2019 through March 1, 2019 and will be updated during annual training. 02/01/2019 Implemented
6400.163(c)Individual #1 had a review of medication prescribed to treat symptoms of a diagnosed psychiatric illness on 8/28/18 and then again on 12/18/18. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.163(c) Psychotropic Medication Reviews (PMR) What specific change will be made: The Agency is developing a Compliance Department with many responsibilities. Pertaining to PMRs, oversight will include ensuring that: Psychiatric reviews are completed at least every 3 months. Documentation includes the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. The physician will either sign the documentation or write the documentation him/herself. Who will make the change? Compliance Department will carry out the directive coordinating with the Compliance Team (composed of a Compliance Department representative, Program Specialist, Administration, and Training Department representative), and implemented by Direct Support Personnel (DSP). When will the change be made: February 1, 2018 How will the change be made: The Compliance Department will: Ensure that all current appointment forms are completed and timely. Ensure that each subsequent scheduled appointment is scheduled within 90 calendar days. An appointment binder and calendar is used by DSP while attending appointments and initiating future appointments. Site Leads and/or Program Supervisors will review calendar/binders weekly and ensure appointments are timely and placed on the agency electronic appointment calendar for review by the Compliance Department/Team. The Compliance Department will ensure that appointments are scheduled within required timeframes. Staff will take individuals to scheduled appointments according to the appointment binder/calendar. If the appointment is not kept due to unforeseen circumstances, the Compliance Department will ensure documentation is completed giving the reason for the missed appointment, with a rescheduled appointment at the medical provider¿s earliest opportunity. What system have you implemented to make sure that the same violation will not occur again: Development of Compliance Department oversight Use of Individual appointment binders and calendars Monthly and quarterly reviews by the Compliance Team What training will be provided to your staff: The Compliance Team developed the review process and will train the Compliance Department on applicable procedures. DSP training on use of the appointment binders and calendars will occur February 1, 2019 through March 1, 2019. Appointment binders and calendars are currently in place and used for all individuals. 02/01/2019 Implemented
SIN-00128677 Renewal 02/09/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(b)The agency did not use the Department's licensing inspection instrument when completing the self assessment on 9/20/17.The agency shall use the Department's licensing inspection instrument for the community homes for people with intellectual disability regulations to measure and record compliance. What specific change will be made: The agency will use the Licensing Inspection Scoresheet for Community Homes, dated 11/17/17, for the the licensing self inspection process.Who will make the change: Program Specialist or designee.When will the change be made: 2/22/2018 How will the change be made: The Program Specialist will utilize the Inspection Instrument, during the specified time frames, 3-6 months prior to license expiration (February, 16 recurring). What system have you implemented to make sure that the same violation will not occur again: A licensing checklist has been developed, to monitor timeliness and completeness of each homes inspection instrument. The Administrative Assistant or designee will collect (during the specified timeframe), each homes licensing instrument; check for completeness, ensure timeliness, in collaboration with the Program Specialist. The checklist and inspection instrument will be submitted to the CEO or designee for review at least 5 business days prior to the expiration of the specified time frame. What training has been provided to your staff: The Program Specialist and Administrative Assistant have been trained in the use of the licensing checklist and completion of the Licensing Instrument.[Documentation of trainings and audits of the self-assessments by the CEO shall be kept. (AS 3/16/18)] 02/22/2018 Implemented
SIN-00200293 Renewal 02/15/2022 Compliant - Finalized
SIN-00169676 Renewal 01/22/2020 Compliant - Finalized
SIN-00108602 Renewal 02/16/2017 Compliant - Finalized