Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250015 Unannounced Monitoring 08/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.171At the time of the inspection the milk in the refrigerator was expired. The milk expired 8/6/2024.Food shall be protected from contamination while being stored, prepared, transported and served. To address the issue of expired milk and ensure that food is protected from contamination throughout all stages of storage, preparation, transportation, and service, the following plan of correction will be implemented: The QLS Residential Staff will be responsible for immediately removing the expired milk from the refrigerator and conducting a thorough review of all food items to ensure that no other expired products are present. Additionally, the team will inspect and rectify any potential issues related to food storage practices that could contribute to contamination or spoilage. To prevent recurrence of this issue, a new protocol will be established. This includes implementing a system for regularly monitoring expiration dates of all food items. The protocol will involve conducting weekly checks of all perishable goods and documenting expiration dates to ensure timely removal of expired items. This system will be integrated into the new online system for staff documentation. 09/30/2024 Implemented
6400.166(a)(2)The name of the prescriber on the Acetamin 500MG tab for Individual #1 does not match the name of the prescriber in the MAR. Dr. Patel is listed in the MAR. Dr. Foulk is listed on the prescription.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.To address the discrepancy between the prescriber's name on the Acetamin 500MG tablet prescription and the name listed in the MAR (Medication Administration Record), the following plan of correction will be implemented: The Medical Coordinator will lead the effort to rectify this issue. Initially, the Medical Coordinator will verify the prescriber information by cross-referencing the prescription with the MAR to ensure consistency. Dr. Foulk, who is listed on the prescription, will be updated in the MAR to reflect the correct prescriber information. To prevent similar discrepancies in the future, the medication record procedures will be reviewed and updated. A new double-check system will be implemented to ensure that prescriber names and other critical details are accurately reflected in the MAR. This verification process will occur monthly during medication changeovers and additionally as needed if medications are changed mid-month. The QLS management team will also be responsible for verifying that the MAR and blister packs match. The Medical Coordinator will oversee this updated procedure to ensure that all records are corrected promptly and consistently. 09/30/2024 Implemented
SIN-00243964 Unannounced Monitoring 05/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)Repeat There was no toilet paper in the upstairs bathroom during the physical site walk through.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. Bathrooms with high foot traffic or frequent use may experience rapid depletion of toilet paper supplies, making it challenging to keep them readily accessible and they may neglect to report empty or low toilet paper to staff, exacerbating the problem by delaying restocking efforts. Cultural differences or personal habits may influence individuals' perceptions of toilet paper usage and availability, leading to variations in consumption patterns. Field Managers will be responsible for overseeing the correction process in the future, which will include implementation of extra toilet paper roll storage in all bathrooms across all homes. By following this plan of correction, we aim to address the immediate need for additional toilet paper storage and prevent future occurrences of inadequate storage by implementing a proactive approach. The house supervisor immediately ensured that there was toilet paper and extra toilet paper in the upstairs bathroom. The Field Manager will place a Toilet Paper Holder Stand (with Reserve Function) in all bathrooms of QLS homes. 06/01/2024 Implemented
SIN-00239312 Renewal 02/21/2024 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)QLS completed self assessment on 3/8/23. There annual was 2/9/23 and their certificate expires on 5/11/23. There self assement did not fall within their time frame.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. 1. A plan to fix the immediate problem a. WHO: QLS Management b. WHAT: QLS Management will ensure that self-inspections are completed within the time frames allotted. c. WHEN and HOW: By April 5th QLS will have established a standardized procedure for documenting self-inspection activities. 04/05/2024 Accepted
6400.71There was no emergency numbers located on the phone in the kitchen at the time of the inspection.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 Field Managers and Staff b. WHAT: All homes will have telephone numbers on or by each telephone c. WHEN and HOW: By April 5th QLS will have established a standardized procedure for phone numbers be 04/05/2024 Accepted
SIN-00236939 Monitoring - Reported Incident 01/03/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the 01/03/24 inspection, the bathtub located in the second floor bathroom had an accumulation of hair and brown and orange grime.Clean and sanitary conditions shall be maintained in the home. 1. A plan to fix the immediate problem a. WHO: QLS Management and Staff b. WHAT: QLS staff will be responsible for ensuring the cleanliness and sanitation of the homes in which they work in. QLS management will be responsible for weekly home inspections. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Implemented
6400.77(b)At the time of the 01/03/24 inspection, the first aid kit did not include tweezers. 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 and Staff b. WHAT: QLS staff will be responsible for ensuring that all first aid kits are equipped and well maintained with the appropriate items. QLS management will be responsible for weekly home inspections, including a comprehensive inventory check of the first aid kits. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly. c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. 02/02/2024 Implemented
6400.80(b)At the time of the 01/03/24 inspection, there were discarded cigarette butts and trash in the side yard to the right of the home when viewed from the street. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.1. A plan to fix the immediate problem. a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for ensuring the outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. 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 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
6400.166(a)(2)At the time of the 01/03/24 inspection, the December 2023 Medication Administration Record (MAR) for Individual #2 did not include the prescribing doctor for Prednisone 10mg; however, Dr. Gauntner was the prescriber listed on the medication blister pack for the December 2023 prescription. The prescribing doctor for Melatonin 3mg on the December MAR is listed as Katelyn Krens, the December 2023 medication blister pack lists Dr. Ashley Swartz as the prescribing doctor for that medication. The prescribing doctor for Risperidone 1mg on the December 2023 MAR is listed as Jamie Showalter, the December 2023 medication blister pack lists Dr. Ashley Swartz as the prescribing doctor for that medication.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
SIN-00195755 Renewal 11/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1's long dresser, right bottom drawer is missing a knob. The home's front wooden steps paint is peeling and nonskid surfaces fading.Floors, walls, ceilings and other surfaces shall be in good repair. . A plan to fix the immediate problem a. WHO: QLS management b. WHAT: QLS management will be responsible for ensuring that all surfaces shall be in good repair in all homes. c. WHEN and HOW: On 1/4/2022 the attached memo was sent out to all QLS Inc., management regarding an additional checklist that will be completed monthly. 01/07/2022 Implemented
6400.74The home's last wooden step out front is missing non-skid surface.Interior stairs and outside steps shall have a nonskid surface. A plan to fix the immediate problem a. WHO: QLS management and staff b. WHAT: QLS management and QLS staff will be responsible in ensuring that all homes are free from hazards monthly c. WHEN and HOW: On 12/30/21 the attached memo was sent out to all QLS Inc., management and staff on the additional checklist that will be completed monthly. 01/07/2022 Implemented
SIN-00161748 Renewal 10/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 10/23/19, the Bathtub on the second floor had approximately 5 grey stains on the bottom of the tub which were described by staff as soap scum stains.Clean and sanitary conditions shall be maintained in the home. Upon Management being made aware of the stains and following up with staff it was discovered that sometime ago the bathtub had previously been treated with an acrylic treatment and that the current cleaner that was being utilized by staff caused the treatment to start separating from the unit and the unit was becoming discolored. The treatment was removed from the tub unit by the maintenance department and the unit underneath was able to be returned to a state in which there were no stains, chips or cracks. (Picture of completed project was already submitted to licenser prior to exit interview.) The QLS Maintenance Department has examined all tub/shower units to ensure that this treatment has not been applied to other units that we occupy. Should any new homes be opened the tub units will be inspected by the QLS Maintenance Department and they will remove any evidence of this product should it have been utilized. In conjunction with the above procedure QLS Field Manager will continue to perform weekly inspections of the home and the Operations Manager will continue to conduct the quarterly inspections that have been completed on an ongoing basis. 11/08/2019 Implemented
SIN-00063445 Renewal 04/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff #1 did not complete the medication administration course before passing medications. Staff #1 only completed 1 of the 2 observations needed. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Provider¿s program that is used to track annual training has been updated to reflect the need for 2 observations. All employee files have been corrected as they have received the correct number of observations since Citation was noted. Please refer to Attachment #1 and #2. 04/17/2014 Implemented
SIN-00265922 Unannounced Monitoring 05/06/2025 Compliant - Finalized
SIN-00258354 Unannounced Monitoring 01/08/2025 Compliant - Finalized
SIN-00117515 Renewal 08/16/2017 Compliant - Finalized
SIN-00076077 Renewal 03/17/2015 Compliant - Finalized
SIN-00046062 Renewal 04/09/2013 Compliant - Finalized
SIN-00040859 Initial review 07/30/2012 Compliant - Finalized