Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00267211 Unannounced Monitoring 06/05/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(2)Individual #1 PRN medication Milk of Magnesia label states the prescriber was Dr. Pharmacy. Medication Administration Record states that the prescriber was not Dr. Pharmacy.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Immediate Correction Plan WHO: QLS Management WHAT: The cited violation in the LIS involved incorrect labeling and prescribing information on OTC PRN medications. WHEN & HOW: Corrective Action Taken: A new label was ordered for the medication, reflecting the correct prescribing physician 6/7/25 06/30/2025 Implemented
SIN-00261460 Unannounced Monitoring 02/27/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the unannounced inspection, in individual #1's bedroom, the wooden trim on the ceiling directly above the trash can attached to the wall and above the wardrobe was loose and needs to be nailed back to the wall.Floors, walls, ceilings and other surfaces shall be in good repair. The root cause of the issue appears to be a lack of routine and systematic inspections of the trim during regular house checks. This led to the failure to notice the loosened trim. To address the immediate issue, the loose wooden trim in individual #1s bedroom will be properly secured to the wall and ceiling by nailing it back into place. 03/31/2025 Implemented
SIN-00256642 Unannounced Monitoring 12/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The door to the staff office is cracked and needs repaired.Floors, walls, ceilings and other surfaces shall be in good repair. Upon observation during a physical walkthrough, it was noted that the staff office door was cracked and required repair. The root cause of the issue was identified as the improper repair of the door initially. To immediately correct this issue, the door was replaced to ensure its proper function and security. 01/20/2025 Implemented
6400.216(a)During the physical site walkthrough, staff reported that Individual #1 has the access code to the staff office to self-medicate. Although Individual #1 is self-medicating, when they enter the staff office on their own to retrieve their medications, the Individual records for both Individual #1 and Individual #2 are then available and unlocked to Individual #1 without staff supervision. An individual's records shall be kept locked when unattended. During the physical site walkthrough, it was reported that Individual #1 has the access code to the staff office to self-medicate. Although Individual #1 is authorized to self-medicate, it was observed that when they enter the staff office on their own to retrieve their medications, the individual records for both Individual #1 and Individual #2 are left unlocked and accessible to Individual #1 without staff supervision. This poses a concern regarding the privacy and security of individual records. 01/20/2025 Implemented
SIN-00244610 Unannounced Monitoring 05/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(g)Individual #1's medication albuterol AER HFA was not in the home at the time of inspection.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.This medication is routinely taken by staff and the individual on outings and is kept in a convenient location for emergencies. Although the intent to have the medication readily available for emergencies is clear, the execution of maintaining its secure and accessible status has proven flawed. Following the inspection, the medication was promptly located and secured in the locked PRN medication box in the staff office. 06/13/2024 Implemented
SIN-00241870 Unannounced Monitoring 03/28/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature at the time of the inspection was 126.1. Hot water temperatures in bathtubs and showers may not exceed 120°F. Preventing hazards and maintaining the safety of the individuals and staff members is very important to the Management Team at QLS. One of the biggest challenges is getting staff members to identify and report hazards and maintain cleanliness to the extent that is required by regulation, which is the root cause of this violation. We employee a diverse group of employees that come from many different walks of life and what are acceptable conditions to one could be viewed as unacceptable by another. The water temperature exceeding the regulated limit has been reduced and all homes have been checked to ensure that they are all within the temperature limits. 05/10/2024 Implemented
SIN-00239310 Renewal 02/21/2024 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Water tests were preformed on 1/11/23,4/20/23,9/11/23, and 1/4/24. They need to be completed 90 days from each other. They did not meet regulatory timeframes.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.1. A plan to fix the immediate problem a. WHO: QLS Field Managers b. WHAT: All water tests will be conducted within 90 days c. WHEN and HOW: By April 5th QLS will have all water tests conducted within 90 days 04/05/2024 Accepted
6400.51(a)(3)Staff #1 had a hire date of 12/18/2023. They did not received training in person centered/community integration/individual choice until 1/23/2024. The time frame is 30 days from hire. There is no grace period for staff training.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.1. A plan to fix the immediate problem a. WHO: QLS Training Coordinator b. WHAT: Ensure all staff are trained within the time periods allotted by regulation c. WHEN and HOW: By April 5th QLS will have all trainings up to date by utilizing the College of Direct Support 04/05/2024 Accepted
SIN-00236937 Monitoring - Reported Incident 01/03/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the 01/03/24 inspection, there was a golf ball sized accumulation of lint in the lint trap of the clothes dryer in the basement. The clothes dryer was not actively being used at the time of the inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.1. A plan to fix the immediate problem a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for ensuring that all floors, walls, ceilings and other surfaces are free of hazards. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Implemented
6400.71At the time of the 01/03/24 inspection, there were no emergency telephone numbers on the cordless phone, the phone charging base, or the wall.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. 1. A plan to fix the immediate problem a. WHO: QLS Management and Staff b. WHAT: QLS staff will be responsible for ensuring that all phones have a label with the appropriate numbers listed on them at all times. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Not Implemented
6400.80(a)At the time of the 01/03/24 inspection, there was an accumulation of snow-covered ice on the rear deck which was slick and unsafe to walk on. Outside walkways shall be free from ice, snow, obstructions and other hazards. 1. A plan to fix the immediate problem. a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for ensuring that walkways are free of hazards. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Implemented
6400.144At the time of the 01/03/2024 inspection, Pro Re Nata (PRN) medications were not available in the home for Individual #1 or Individual #2.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. 1. A plan to fix the immediate problem. a. WHO: QLS Management and Staff b. WHAT: QLS Management will ensure that all PRN medications are always available in the home to the individuals. QLS staff will audit and report PRN medication needs. c. WHEN and HOW: Effective 2/1/2024 all PRN medications will be audited by staff members in the homes weekly and reported back to the Medical Coordinator by Tuesdays at noon of any medications that are low, or close to expiration. 02/02/2024 Implemented
6400.214(a)At the time of the 01/03/24 inspection, the current Annual Assessment and ISP for Individual #1 and Individual #2 were not at the home.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.1. A plan to fix the immediate problem. a. WHO: QLS Management b. WHAT: QLS Management will ensure that the staff have access to the most recent assessment, physical, ISP, Behavior Support Plan and any other pertinent information specific to the individual being served c. WHEN and HOW: QLS Program Specialist, Medical Coordinator and Behavior Specialist will ensure that all records are kept in digital and paper form in the homes for the staff by 2/1/2024. 02/05/2024 Not Implemented
6400.163(g)At the time of the 01/03/24 inspection, seven pills of different shape, size and color were together in a plastic sandwich bag bound with a rubber band in the bottom of the medication box used to store Individual #2 medications.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.1. A plan to fix the immediate problem. a. WHO: QLS Medical Coordinator, management and Steff b. WHAT: QLS Medical Coordinator will ensure all medications are stored properly and disposed of properly if necessary. QLS management will inspect the medication storage weekly during unannounced inspections. QLS staff will ensure proper storage/disposal daily of medications c. WHEN and HOW: QLS Medical Coordinator will ensure that all homes are equipped with a locked medication box, and instructions for disposing of refused medications by 2/1/2023. 02/02/2024 Implemented
6400.166(a)(2)At the time of the 01/03/24 inspection, the December 2023 Medication Administration Record (MAR) for Individual #1 listed the prescribing doctor for Chlorpromazine 100mg and Fluvoxamine 50mg as Dr. Laura O'Farrell; however, Dr. James Gides was the prescriber listed on the medication blister packs for both December 2023 prescriptions. At the time of the 01/03/24 inspection, the December 2023 MAR for Individual #2 listed the prescribing doctor for Topiramate 200mg as Dr. Laura O'Farrell; however, Dr. James Gides was the prescriber listed on the medication blister pack for the December 2023 prescription.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.1. A plan to fix the immediate problem. a. WHO: QLS Medical Coordinator b. WHAT: QLS Medical Coordinator will ensure that all medication records have complete and accurate information. c. WHEN and HOW: QLS Medical Coordinator will work with the pharmacy and the eMar System in order to ensure all medication records are accurate and complete by 2/1/2024 02/02/2024 Not Implemented
6400.186At the time of the 01/03/24 inspection, there were no documents kept to track the calorie or fluid intact for Individual #2. Individual #2 most recent Individual Support Plan (ISP) states that Individual #2 is not to consume more than 1800 calories per day and is to ingest between 2000 and 2500cc of fluid per day.The home shall implement the individual plan, including revisions.1. A plan to fix the immediate problem. a. WHO: QLS Management and Staff b. WHAT: QLS Program Specialist will ensure that all revisions to the individual plan are made available for staff immediately via the online database and update the individual binder within the home. QLS Program Specialists will monitor that all plans are being implemented. QLS Staff will review any revisions and sign off that they have read and understand them as well as begin implementing the changes. c. WHEN and HOW: QLS Medical Coordinator will ensure all homes have received training on any and all medically related restrictions, recommendations, practices for each individual. QLS Behavior Specialist will ensure that staff are trained on all behavioral support plans, restrictions, non-restrictive environmental adaptations. QLS Program Specialists will ensure that all staff are trained on the individual plans and are implementing them by conducting weekly audits of documentation in the homes. QLS management will be conducting weekly house inspections to ensure compliance with this regulation. 02/02/2024 Implemented
SIN-00220437 Unannounced Monitoring 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)The Agency Medical Services Policy Number 04-001 reads "Written informed consent MUST be filed and maintained in the individual's files". Consent forms were not acquired for the Neurologist, Orthopedist or Dentist who provided support to Individual # 1. Requests for Neurologist physician summaries were not able to be acquired by the agency. Staff # 7 confirmed via email that Consent for Release of information was only obtained for the Primary Care Physician and Psychiatrist.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. 1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator b. WHAT: QLS Medical Coordinator will be responsible for ensuring the written informed consent is kept and maintained for all medical providers for each individual. c. WHEN and HOW: On 3/30/23 a memo was released to QLS management to inform them that consents for all medical providers for each individual must be obtained and scanned into their medical chart by 4/14/2023. 04/14/2023 Implemented
6400.43(b)(3)A summary from a medical appointment on 09/19/22 reads "Care staff reports that they have had to hook their arms under patient to prevent her from falling." Staff # 1 was retrained in use of Gait belt on 09/21/22. There is no documentation that Staff # 2-5 were retrained in the use of the gait belt. Staff # 7 confirmed via email on 01/27/23 that hooking under arms is "not acceptable" and that only Staff # 1 was retrained on 09/21/22 due to being the only target of the investigation. Incident report # 9092713 was created due to bruising identified on 09/15/22. The incident report reads "I interviewed staff #4 she stated that sometimes because Individual # 1's gait belt isn't enough when she falls you have to grab her arms to help her, and then she will get marks afterwards." There is no documentation that Staff # 4 was retrained in the use of a gait belt". The incident report also reads "I interviewed staff # 1 she stated that when Individual #1 falls and you try to prevent it from happening sometimes it ends with a mark on her."The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. 1. A plan to fix the immediate problem a. WHO: QLS Training and Recruitment Coordinator b. WHAT: QLS Training and Recruitment Coordinator will ensure that all staff are appropriately retrained when involved in an incident, not just the target of the investigation. QLS training and Recruitment Coordinator will ensure that all staff are appropriately trained on the use of assistive/adaptive technology. c. WHEN and HOW: On 3/30/23 a memo was issued to QLS management team describing the importance of retraining all staff in the home when an incident occurs not just the target of the investigation. 03/31/2023 Implemented
6400.67(a)A quarter size hole is in the half door at the bottom of the stairwell.Floors, walls, ceilings and other surfaces shall be in good repair. 1. A plan to fix the immediate problem a. WHO: QLS maintenance department, management, staff b. WHAT: The QLS Maintenance team repaired the hole in the door at the bottom of the steps at this location. c. WHEN and HOW: On 1/24/2023 QLS maintenance team was dispatched to the location and repaired the hole in the door at the bottom of the steps at this location. 01/24/2023 Implemented
6400.77(b)Tweezers and Scissors were not in the first aid kit during the physical site walk through. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. 1. A plan to fix the immediate problem a. WHO: QLS Management b. WHAT: Scissors were kept in a separate locked box in this home, QLS management relocated scissors to the first aid kit. c. WHEN and HOW: On 1/23/2023 QLS management placed scissors in the first aid kit. 01/23/2023 Implemented
6400.144Individual # 1 went to Tri Community Center on 09/19/22 due to bruising. The History of Present Illness from the medical document reads "Family states that they have noticed that patient is off balance. Family and staff voice concerns that patient had previously received 1:1 care but recently was placed with a roommate- now 2 consumers to 1 caregiver. Patient does have ecchymotic area noted to upper extremities and x1 to face. Care staff reports that they have had to hook their arms under patient to prevent her from falling. Pt. also requires assistance with ambulation to prevent falls. Staff states that patient is unsteady on her own." Physician discharge recommendations reads "Problem # 1 Frequent Falls···ensure adequate staff to help with ambulation and transfers". Individual # 1's ISP dated 07/01/21 and 07/21/22 both read "1:1 staffing with a request has been completed for supplemental habilitation to support Individual # 1. 1 staff and 1 aid. Intensive staffing is needed to assist Individual # 1 in her daily needs, kitchen safety as well as assess the severity of her seizures and if she has elopement issues". The Restrictive Procedure plan reads "Hand over hand supervision when not in wheelchair in high populated/high traffic areas for ambulatory needs and safety, will fade upon doctor's request".A summary from a medical appointment on 09/19/22 reads "Care staff reports that they have had to hook their arms under patient to prevent her from falling." Staff # 1 was retrained in use of Gait belt on 09/21/22. There is no documentation that Staff # 2-5 were retrained in the use of the gait belt. Staff # 7 confirmed via email on 01/27/23 that hooking under arms is "not acceptable" and that only Staff # 1 was retrained on 09/21/22 due to being the only target of the investigation. Incident report # 9092713 was created due to bruising identified on 09/15/22. The incident report reads "I interviewed staff #4 she stated that sometimes because Individual # 1's gait belt isn't enough when she falls you have to grab her arms to help her, and then she will get marks afterwards." There is no documentation that Staff # 4 was retrained in the use of a gait belt". The incident report also reads "I interviewed staff # 1 she stated that when Individual #1 falls and you try to prevent it from happening sometimes it ends with a mark on her."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. 1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator and program department b. WHAT: QLS Medical Coordinator will review medical appointment summaries and report any dietary, psychological, medical, nursing, pharmaceutical and dental services that are planned or prescribed to the QLS program department. The two departments will work together to ensure that these services are arranged and provided. c. WHEN and HOW: On 3/30/23 a memo was released to educate the team on the proper protocol for services planned or prescribed for the individuals. 03/30/2023 Implemented
6400.18(a)(9)On 12/03/22, Staff #2 identified a bruise on Individual # 1's back. This was photographed as body chart 1916. Incident Management Bulletin 00-21-02 identifies "Bruising to an area of the body which does not typically or easily bruise (e.g. midline stomach, breasts, genitals, inner thighs or middle of the back)." to be reported within 24 hours of identification. An Incident report was not filed for this injury. On 12/20/22, Staff # 2 identified bruises "on her left cheek on her butt", "a small bruise on her left arm" and a "Bruise on chest notice bruise on her neck on left side". Incident Management Bulletin 00-21-02 identifies "Unexplained serious injuries or multiple bruises, cuts, abrasions. Must be reported within 24 hours of identification. An incident report was not filed for these injuries. On 10/19/22 Staff # 4 identified a bruise "on the left side of her back". This was photographed as body chart # 1768. Incident Management Bulletin 00-21-02 identifies "Bruising to an area of the body which does not typically or easily bruise (e.g. midline stomach, breasts, genitals, inner thighs or middle of the back)." to be reported within 24 hours of identification. An Incident report was not filed for this injury.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Injury requiring treatment beyond first aid. 1. A plan to fix the immediate problem. a. WHO: QLS Management b. WHAT: Incident reports were entered for bruising c. WHEN and HOW: On 2/1/2023 incident reports were entered for bruising and investigations were launched. 03/31/2023 Implemented
6400.52(c)(6)Staff # 1-5 did not receive in person training for Individual # 1's Individual Plan Implementation.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.1. A plan to fix the immediate problem a. WHO: QLS program department b. WHAT: QLS program department will ensure that all staff working with individuals are trained on the individual plan c. WHEN and HOW: During month behavior support plan meetings, held on 3/28/22 the program team will review and train the staff on the individual plan and a staff training form will be completed to document staff were trained on individual specific plans 03/30/2023 Implemented
6400.182(a)Individual # 1's ISP last updated 12/09/22 reads, "Last Seizures were in September 2022-She had 2". An email from the Service Coordinator dated 01/27/23 reads "SC switched date accidentally to September due to appointment in September. ISP will be updated to reflect this.". The revision to the ISP to correct this Seizure information was not identified or requested to be revised by staff # 6 from 12/09/22 to 01/27/23.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.1. A plan to fix the immediate problem. a. WHO: QLS Program Department b. WHAT: The program team will ensure that there are no discrepancies within the individual plan. c. WHEN and HOW: One 1/27/23 the SC was contacted regarding the discrepancy in the plan and the need for the changes to be made. 01/27/2023 Implemented
SIN-00175842 Unannounced Monitoring 09/01/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There was a large pool of water over six feet in diameter in the basement by the steps. Floors, walls, ceilings and other surfaces shall be free of hazards.1. 6400.67 (b)- surfaces- floors, walls, ceilings shall be free of hazards. There was a large pool of water in the basement near the steps. a. It is the responsibility of the RSS and house supervisors to report any hazards to the maintenance department via the maintenance on call system. This to allow things to be fixed immediately as to not cause harm or injury to anyone in the home. The maintenance department will fix the immediate problem and outsource anything that may need additional attention. b. The pool of water was cleaned up and QLS Inc. maintenance department has scheduled to place a sump pump in the basement on 9/30/2020. c. The pool of water was cleaned up on 9/8/2020 and the home is currently free from this hazard. 2. Outside of COVID-19 restrictions, QLS Inc. typically has a field manager visit all the homes on a weekly basis and provide maintenance request forms to all managers submission to the maintenance department. 3. A memo has been sent out on 9/17/2020 addressing this regulation and the role that RSS and house supervisors play while awaiting COVID-19 restrictions to be lifted. 4. No new form or plan was created due to the prior success of the policy this was simply overlooked as an effort to minimize COVID-19 exposure to the people we support. 5. Attachment #1- Memo Attachment #9- photo of dried basement floor 09/08/2020 Implemented
6400.76(a)Individual #1's recliner was broken and falling apart at the time of the inspection. Furniture and equipment shall be nonhazardous, clean and sturdy. 1. 6400.76 (a)- furniture and equipment- recliner in the living area was broken and falling apart. Furniture and equipment should be nonhazardous, clean, and sturdy. a. WHO: It is the responsibility of the RSS and house supervisors to report any hazardous, broken, and unsafe furniture to the maintenance department. They will do their best to come and repair what is broken. If they cannot fix it, they will purchase new furniture. b. The recliner was repaired by the QLS Inc. maintenance department c. The recliner was repaired on 9/8/2020. 2. Outside of COVID-19 restrictions, QLS Inc. typically has a field manager visit all the homes on a weekly basis and provide maintenance request forms to all managers submission to the maintenance department. 3. A memo has been sent out on 9/17/2020 addressing this regulation and the role that RSS and house supervisors play while awaiting COVID-19 restrictions to be lifted. 4. No new form or plan was created due to the prior success of the policy this was simply overlooked as an effort to minimize COVID-19 exposure to the people we support. 5. Attachment #1- Memo Attachment #8- photo of fixed recliner 09/08/2020 Implemented
SIN-00162687 Unannounced Monitoring 08/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)REPEAT from 9/11/18 annual inspection: There were numerous clothing and personal items found lying in outdoor rock salt on the top of the basement steps and lying scattered on the unfinished, damp and wet, concrete basement floor. Those items were individual's clothes, pillows, stuffed animals, and blankets. Some of these items were spilling out of plastic bags that were not tied shut or contained rips. There was a puddle of water approximately 2 feet by 8 feet on the basement floor. The ceiling fan in the first floor bathroom contained approximately a quarter of an inch of dust.Clean and sanitary conditions shall be maintained in the home. On August 9, 2019 the residential staff persons that were on shift during the unannounced addressed the areas of concern, attached as Exhibit #16a and 16b are pictures showing the deficiencies were addressed. Also, on August 9th, 2019 Operations Manager spoke with the landlord about the water that puddles on the floor after a heavy rain and he stated that by October 31, 2019 that he would have new floor drains installed and he would have one installed in the area of concern. In the meantime, the residential staff and maintenance staff are going to monitor the situation and squeegee the water to the closet drain. As the Field Manager currently inspects the homes weekly to ensure their compliance and the Operations Manager inspects the homes periodically multiple times a year to make sure that the homes are being maintained, effective September 1, 2019 we started to have the Behavioral Specialist hold their monitoring meetings in the homes at which time they also complete a site inspection for cleanliness of the home as well as items in need of repair. The Field Manager is still responsible for a more thorough inspection, but we have incorporated having the Behavioral Specialist do a quick oversight of the home. All managers are required to complete maintenance work orders for items in need of repair and cleaning lists for the staff detailing items that need addressed. The staff then are required to complete the tasks and forward pictures to the inspecting manager verifying that the issue was addressed. Upon the inspecting managers receipt of the picture they document the cleaning list of its completion and they work with the house staff to ensure that all items have been addressed. The Field Manager¿s House Inspection Checklist has been updated to include the responsibility of specifically checking that the ventilation fans in the bathroom are free of dust build up, attached as Exhibit #17. 09/01/2019 Implemented
6400.64(b)REPEAT from 9/11/18 annual inspection: The home was treated for a bed bug infestation on 1/31/19, 2/13/19, 2/26/19, and 3/7/19 due to agency staff reporting the continued findings of bed bugs throughout the home. On 7/30/19, the residential agency instructed Terminix to inspect Staff #1's personal home for bedbugs as a bedbug was found at a residential home she worked at. Terminix did not inspect Staff #1's apartment until 8/7/19 in which they reported to Staff #2, "it seems to be the worst one yet." During the 8/9/19 onsite inspection, Staff #2 reported that the agency was aware that Staff #1 worked at this residential home in the last month and as of 8/7/19, her personal home was still infested with bedbugs. Prior to the 8/9/19 onsite department inspection, the agency did not contact Terminix to inspect the residential home since their knowledge of recent bedbug infestation at a staff's home, whom works at this residential home.There may not be evidence of infestation of insects or rodents in the home. On August 9, 2019 during the announced inspection QLS Operations Manager contacted Terminix and made their owner aware of the escalated nature of the situation. Terminix was able to get an inspector and treatment technician out to inspect the homes that were awaiting inspection and to treat the home noted above. Please see Exhibit #1 - Account Invoice as proof that this home was serviced on August 9, 2019. QLS has developed a Policy and Procedure for the Treatment of Bed Bugs, attached as Exhibit #2 as well as a Bed Bug Encounter Log, attached as Exhibit #3 that will be completed by the assisting manager for the encounter and overseen by the Administrative Assistant. The log will capture time sensitive data and ensure that the individuals health and safety are being taken into consideration and that the process is being monitored closely. In the event that there would be a lag in communication with the Terminix Inspector or Treatment Technician immediate action will be taken and noted. Furthermore, a meeting is being scheduled between our Management and Terminix to review the policy and the level of service response time that is required. 09/23/2019 Implemented
6400.72(b)REPEAT from 9/11/18 annual inspection: The screen in the rear screen door, contained approximately a 5-inch rip. Screens, windows and doors shall be in good repair. The screen door was replaced on August 9, 2019 and the invoice and picture of the newly installed door is being forwarded to you as Attachment #8a & 8b There has been a change of staff in the Field Manager Position and the current Field Manager was unaware that the screen was enclosed within the door so that screen was never inspected during the weekly house inspections. The Field Manager has now been made aware to look for those types of screens in the storm doors as they are becoming very common. The Field Manager House Inspection Checklist has been updated to specifically inquire about checking the screen doors for the possibility of other homes still having this style of door, attached as Exhibit #17. QLS has requested that their maintenance department no longer installs that style of screen doors on the homes as it seems inevitable that the screen gets caught and ripped somehow in the machinal mechanism. The Operations Manager will inspect the homes periodically multiple times a year to make sure that the homes are being maintained in good condition. The operations department will document each home inspection with an already existing house inspection form. 08/09/2019 Implemented
SIN-00117510 Renewal 08/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Coliform water testing completed on 7/28/19 and not again until 11/4/16.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Upon recognition that a Coliform Water Test was not performed within the time frame specified in regulation 6400.68(c) a water test was completed immediately to comply with regulation. The management of Quality Life Services, Inc is going to continue to use the Well Water Tracking Chart that has been previously utilized to track these test, but the Operations Manager is now the party responsible for initiating the testing when it is due. The Operations Manager will contact the house supervisor the day the water sample needs to be drawn and inform them that the test needs to be performed and the steps they need to take to perform the test. Upon the House Supervisor dropping the water sample off at the testing site they will contact the Operations Manager and inform her that the water sample has been dropped off at such time she will make note that the sampling was completed and she will await results of said testing. After receiving the test results the Well Water Tracking Chart will be updated as well as the Operations Managers Daily Planner to denote the date that the next Coliform Water Test needs to be performed. This plan of correction has been utilized and found to be functional to remain in compliance since November 4, 2016 when management noticed the failure of compliance in this area. Attachment #1 is a copy of the tracking for the licensed home showing that there haven¿t been any further instances of testing not being completed within the time frame specified in regulation 6400.68(c) as well as Attachment #2 being the Coliform Water Test Policy that was developed and the acknowledgement that the Operations Manager was trained on said policy. 11/04/2016 Implemented
SIN-00076067 Renewal 03/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)The fire drill log for 7/6/2014 did not include if all the individuals met at the meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Fire Drill's have been revised to have a signature of the Operations Manager after they are found to be compliant. 03/23/2015 Implemented
6400.164(b)Individual #1's 3/19/2015 medication log did not have the 8am medications logged off immediately. The medication log was not signed off on but the medications were adminstered. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. A Memo was sent out to all house for each employee to review on the steps to proper medication administration. In addition to the 2 Annual Medication Observations the Managers will perform their house checks around medication administration times to ensure that the proper steps are being taken when administrating medications. 03/23/2015 Implemented
6400.181(e)(1)Individual #1's assessment did not address her needs and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.181(e)(12)Individual #1's assessment did not review recommendations specific to areas of training, progreamming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.181(e)(13)(i)Individual #1's assessment did not include progress over the last 365 calendar days and current level in health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.181(e)(13)(ii)Individual #1's assessment did not include progress over the last 365 calendar days and current level in motor and communication skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.181(e)(13)(iii)Individual #1's assessment did not include progress over the last 365 calendar days and current level in activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.181(e)(13)(iv)Individual #1's assessment did not include progress over the last 365 calendar days and current level in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment did not include progress over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.181(e)(13)(vi)Individual #1's assessment did not include progress over the last 365 calendar days and current level in recreation. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. All Assessments have been updated to show advancement in this area as well as the Program Specialists have received a clearer picture that what the regulation is really looking for in this area is any type of change, either positive or negative. 04/13/2015 Implemented
6400.183(7)(i)Individual #1's ISP did not include an assessment for the potential to advance in residential independence. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Residential independence. All ISP's have been reviewed and e-mails were sent to the SC's asking them to please make the necessary changes. Also, the ISP Review Sheet that QLS used previously has been modified to include verification that this content is contained in the ISP. 04/24/2015 Implemented
6400.183(7)(iii)Individual #1's ISP did not include an assessment for the potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. All ISP's have been reviewed and e-mails were sent to the SC's asking them to please make the necessary changes. Also, the ISP Review Sheet that QLS used previously has been modified to include verification that this content is contained in the ISP. 04/17/2015 Implemented
6400.183(7)(iv)Individual #1's ISP did not include an assessment for the potential to advance in competitive community-integrated employment. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. All ISP's have been reviewed and e-mails were sent to the SC's asking them to please make the necessary changes. Also, the ISP Review Sheet that QLS used previously has been modified to include verification that this content is contained in the ISP. 04/17/2015 Implemented
SIN-00195752 Renewal 11/30/2021 Compliant - Finalized
SIN-00180453 Renewal 12/07/2020 Compliant - Finalized
SIN-00046057 Renewal 04/09/2013 Compliant - Finalized