Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280612 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At 12:05 PM on 12/10/25, several of the flooring boards in the home's finished attic area were missing, exposing insulation, open joist cavities, and electrical wiring, thus, posing safety hazards. The home's finished attic, was constructed with greater than six feet of standing room and is currently being utilized for storage. Floors, walls, ceilings and other surfaces shall be free of hazards.The maintenance department installed new subfloor on 1/15/25 01/15/2026 Implemented
6400.81(k)(6)At 11:29 AM on 12/10/25, Individual #1's bedroom did include a mirror. Individual #1's current Restrictive Procedure Plan, dated 4/21/25, did not include any language or reference to the restriction of a mirror in Individual #1's bedroom or home. In addition, Individual #1's Service Plan, last updated 11/5/25, did not contain any language or reference to the following: Individual #1's choice not to have a mirror in their bedroom; a medical condition prescribed or recommended by a physician requiring an alternative to having a mirror in Individual #1's bedroom; or a behavioral need that could be exacerbated by the presence of a mirror in Individual #1's bedroom.In bedrooms, each individual shall have the following: A mirror. Mirror was installed in bedroom on 12/12/25 by the Maintenance Department. 01/15/2026 Implemented
6400.82(f)At 11:26 AM on 12/10/25, the home's only bathroom did not include a wall mirror hung at a viewable level in which Individual #1 can utilize for completing basic hygiene. This bathroom included only a mirror that was installed on the wall above the tub and shower area at a height of six feet and 11 inches from the floor. Individual #1's current Restrictive Procedure Plan, dated 4/21/25, did not include any language or reference to the restriction of a mirror in Individual #1's home. In addition, Individual #1's Service Plan, last updated 11/5/25, did not contain any language or reference to the following: a medical condition prescribed or recommended by a physician requiring an alternative to having a mirror in Individual #1's bathroom; or a behavioral need that could be exacerbated by the presence of a mirror in Individual #1's bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Mirror was installed in bathroom on 12/12/25 by maintenance personnel. 01/15/2026 Implemented
6400.32(h)At 11:10 AM on 12/10/25, the home was equipped with Ring cameras installed in the living room and staff office that are both located on the first floor. Individual #1's current Restrictive Procedure Plan, dated 4/21/25, documented that Individual #1 provided their verbal consent to the use of a camera in the home's staff office due to threats that Individual #1 had made to staff in the past. However, Individual #1's current Restrictive Procedure Plan did not include the following to establish Individual #1's full consent to the use of Ring cameras in the home: the use of a camera in the home's living room and its intended purpose; the type of feed (visual and/or audio) that the home's cameras capture; the identification of those who can access the feed and/or recordings; and the length of time for which any captured recordings are stored. Therefore, without the agency having provided full disclosure to Individual #1 regarding the use of cameras in the home, Individual #1's consent was not obtained, resulting in an intrusion upon their right to privacy of person and possessions.An individual has the right to privacy of person and possessions.Program Specialist will go over the updated Video Surveillance Acknowledgement form at the Individuals Quarterly meeting with his team to get consent. The Video Surveillance Acknowledgement form will be kept in his record. 01/23/2026 Implemented
6400.52(a)(1)Direct Service Worker #1 completed 22.10 documented hours of annual training for the 2024-2025 fiscal year on 7/25/24 in the following required topics, which were documented on their College of Direct Supports transcript: "Person-Centered Planning" (2.0 hours), "Community Inclusion" (3.1 hours), "Individual Rights and Choice" (1.0 hours), "Individual Choice" (3.0 hours), "Dynamics and Challenges of Developing and Maintaining Relationships" (2.0 hours), "Developing and Maintaining Relationships" (2.0 hours), "Job-Related Knowledge and Skills: Overview of DSP Job Duties" (3.0 hours), "Implementation of the ISP and Safe and Appropriate Use of BSP Training" (1.5 hours), "Fatal Five (Plus One)" (1.0 hours), "Agency Contingency Plan" (1.0 hours), "Sexual Harassment Training" (0.5 hours), and "Job ISP/ BSP Review/ Physical Crisis Intervention" (2.0 hours). This does not meet the 24 hours of training as required by regulation.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.The training department has started documenting all dates of training hours instead of just the completed date of the training to reflect an accurate record of Employee training hours completed in college of direct support and agency trainings. 01/15/2026 Implemented
6400.186Individual #1's Service Plan, last updated 11/5/25, stated, "[Individual #1] has not attempted to ingest or misuse poisonous materials. [However], due to [Individual #1's] impulsivity and threats of self-harm, poisonous materials are secured in the staff office." At 11:18 AM on 12/10/25, located underneath the kitchen sink were the following unlocked poisonous cleaners: an 18-Pad box of SOS Steel Wool Soap Pads; a 10-pad box of Great Value Steel Wool Soap Pads; and 75 fluid-ounce bottle of Great Value of Dish Liquid Soap with directions to contact Poison Control if absorbed or ingested.The home shall implement the individual plan, including revisions.On 12/10/25 the poison materials were locked back up in the staff office 01/15/2026 Implemented
SIN-00238452 Renewal 01/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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
6400.65On 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
SIN-00200298 Renewal 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 2/16/22, at 10:26 AM, the water temperature at the bathroom sink on third floor measured 127.9 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. A maintenance staff member was immediately notified of the hot water temperature area of non compliance, and was sent to assess and resolve the matter, by turning down the hot water heater's control to reduce the water temperature below 120 degrees f. [A copy of the agency's Residential Standards Policy, which includes daily checks of hot water temperatures in all residential settings, was received on 2/22/22 and reviewed 2/28/22. A template for documentation of hot water temperatures for each source accessible to individuals was received on 2/22/22 and reviewed on 2/28/22. A blank copy of the maintenance request form, to be completed if a water temperature is above 120 degrees Fahrenheit was received on 2/22/22 and reviewed 2/28/22. DPOC by HDKP, HSLS, on 2/28/22]. 02/22/2022 Implemented
SIN-00184818 Renewal 03/16/2021 Compliant - Finalized