Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247295 Unannounced Monitoring 07/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Individual #1's MAR was not logged immediately after administration for all 8pm medications on July 2nd.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.To address the issue of medications not being signed off at the time of administration, we will implement a comprehensive plan of correction. We will enable a feature on our Electronic Medication Administration Record (eMAR) system that includes alert functions. By 8/5/2024 The system will notify the house supervisor and medical coordinator if a medication is not signed off within 30 minutes of the scheduled administration time. The eMAR system will be configured to send immediate alerts to the house manager or supervisor via SMS and/or email if a medication is not signed off within the specified timeframe. 08/05/2024 Implemented
SIN-00241909 Unannounced Monitoring 03/28/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #2's March 2024 Medication Administration Record states that they are prescribed Acetaminophen tab 325mg PRN. This medication was not available in the home at the time of the inspection.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. It is important for individuals to have their prescribed medications available to them. It is apparent that there have been instances in which individuals were prescribed PRNs and they weren't in their home and available to them or that a medication was discontinued, and an oversight occurred in which it wasn't discontinued from the EMAR system. The Management Team has verified that all PRN medications are available to the individuals and that the MARS contain the current prescribed PRN medications. 05/10/2024 Implemented
SIN-00237048 Unannounced Monitoring 01/03/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(2)Individual #1's bed appeared to have a mattress dip. The mattress was sitting on a box spring which sat directly on the floor. Given the size of the Individual, it was apparent that the mattress/box spring is no longer in good condition and is not comfortable. Additionally, Individual #1 stated that the mattress was very uncomfortable.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. 1. A plan to fix the immediate problem a. WHO: QLS Management, Maintenance and Staff a. WHAT: QLS staff will be responsible for ensuring that all individuals beds remain clean, comfortable and sanitary as will as the foundation remains in good repair. QLS management will be responsible for weekly home inspections, including an inspection of the beds and mattresses for the individuals. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly. QLS Maintenance will replace any mattresses that are stained, damaged, or no longer providing a comfortable sleeping surface. QLS Maintenance will repair or replace any foundations that are unstable or damaged. b. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections and reported to maintenance any repairs or replacements that are needed 02/02/2024 Not Implemented
6400.182(c)Individual #1's current ISP dated 8/17/2023 states that there are door alarms set at the home. At the time of inspection, no door alarms were present. Based on the current assessment dated 6/16/2023, it also does not indicate that there are door alarms present. The individual plan was not revised when the Individual's needs changed.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.1. A plan to fix the immediate problem. a. WHO: QLS Program Specialists b. WHAT: QLS Program Specialists will ensure immediate updates to individual plans based on the latest assessment and any change of needs that occur, by conducting timely and accurate addendums and revisions as needed. c. WHEN and HOW: QLS program specialists developed a streamlined communication process between the departments for accurate information regarding revisions and updates to individual plans, this was put into effect on 1/22/2024. 02/02/2024 Implemented
SIN-00175772 Unannounced Monitoring 09/01/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The top 3 steps leading to the front door do not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. 1. 6400.73 (a)- handrails and railings- Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Top three steps leading to the front door was missing a handrail. a. RSS, house supervisors, and program specialists will be responsible for checking to assure handrails are present, safe, and secure. This is for the interim until the field manager can return to completing house checks. If there is an issue with the handrails or railing a call to the on call maintenance number should be completed as this is safety hazard. b. QLS Inc. maintenance team added handrails to accommodate the top three steps. c. The new handrails were installed 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 # 10- photo of additional handrails added 09/08/2020 Implemented
SIN-00160796 Renewal 10/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Immunizations (Tetanus/Diphtheria) were marked unknown on physical form dated 4/2/19. Individual #1 was accepted in to the program without required immunizations. Individual #1 received the Tetanus vaccination on 6/11/19. As of 10/24/19, she has not received the Diphtheria vaccine.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The physician's office that administered the shot on June 11, 2019 was contacted and confirmation was obtained that the individual was given both Tetanus/Diphtheria when the shot was administered. The Medical Services Policy and Procedure was revised to include specific language regarding the documentation and administration of Tetanus/Diphtheria shots. The Individual's Physical form has also been updated to include additional language instructing the medical personal to administer the Tetanus/Diphtheria shot if the date is unknown. Attached as Exhibit #2 is a copy of the revised Medical Services Policy and Procedure, Exhibit #3 the documentation showing that the individual was administered a Tetanus/Diphtheria shot on June 11, 2019 and Exhibit #4 the page of the individuals physical showing the additional language that was added. Each physical is signed off by the Medical Coordinator prior to the admission of an individual to ensure that the physical meets the requirements for regulatory compliance. 11/01/2019 Implemented
6400.144On July MAR's (Medication Administration Records) it is documented that individual #1 started taking Mupirocim 2% cream on 7/25/19 for an infected shoulder. The Mupirocim cream was then discontinued on 8/16/19. There is no documentation of a medical professional assessing the infected shoulder initially or once infection was resolved.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. The Medical Services Policy and Procedure was revised and additional language was incorporated into the policy to address the requirement for documentation of Urgent Care appointments, as well as follow up appointments must happen in order for the medication to be discontinued. Attached as Exhibit #2 is a copy of the revised Medical Services Policy and Procedure. A quarterly review of individuals medical records will occur to ensure that the Policy and Procedure is being adhered to. 11/01/2019 Implemented
6400.181(e)(4)Individual #1 is on a restrictive procedure plan which include sharp objects being locked, door alarms, window limiters and physical restraints being used. This information in not listed in her assessment. The assessment must include the following information: The individual's need for supervision. Prior to the exiting meeting on October 24, 2019 there was an Addendum to the Individuals Assessment which included the individual's need for supervision. QLS management met and determined that the best place to display this information in the individuals Assessment is under the Individuals Need for Supervision that correlates with Regulation 181e4. The Operations Manager has edited the database to added a locked subsection to the above referenced portion of the Assessment. This newly added subsection is titled Restrictive Procedures to be Utilized by Trained Quality Life Services, Inc. Staff Members. All individuals that needed this newly developed section had Addendums to their Assessments completed by November 30, 2019 that contained the Restrictive Procedures that are implemented through the individuals approved behavioral support plan. Attached as Exhibit #1 is a copy of an Addendum showing the newly developed subsection. 11/30/2019 Implemented
SIN-00277305 Unannounced Monitoring 10/30/2025 Compliant - Finalized
SIN-00267210 Unannounced Monitoring 06/05/2025 Compliant - Finalized
SIN-00261457 Unannounced Monitoring 02/27/2025 Compliant - Finalized
SIN-00258351 Unannounced Monitoring 01/08/2025 Compliant - Finalized
SIN-00251708 Unannounced Monitoring 09/17/2024 Compliant - Finalized
SIN-00230670 Renewal 09/12/2023 Compliant - Finalized
SIN-00199209 Renewal 02/15/2022 Compliant - Finalized
SIN-00117520 Renewal 08/16/2017 Compliant - Finalized
SIN-00049167 Initial review 04/09/2013 Compliant - Finalized