| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The provider's certificate of compliance expires on 02/16/24. The window for the home to complete the self-assessment is between 08/16/23 and 11/16/23. The home completed the self-assessment on 11/30/23. | 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.
| Lifeway Services Standards & Compliance Director (or designee) will utilize the company internet calendar system to track and maintain the timeframe for the self assessment and the associated deadlines. |
02/28/2024
| Implemented |
| 6400.65 | On 1/18/2024, at approximately 12:17 PM, the second-floor bathroom had a large sheet of plexiglass mounted over the bathroom window, preventing the window from opening. The second-floor bathroom was not equipped with a mechanical ventilation system. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The second floor bathroom was equipped with a mechanical exhaust fan in the ceiling, on 2/15/2024 by the maintenance dept. |
02/15/2024
| Implemented |
| 6400.141(a) | Individual #1 had a physical examination completed on 10/05/22 an then again on 11/27/23. This exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Lifeway Service's Health & Wellness Coordinator (or designee) will manage and audit the agency's medical appointment tracker on a monthly basis to ensure that all required appointments are maintained within the required timeframes. |
02/28/2024
| Implemented |