Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256647 Unannounced Monitoring 12/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)At the time of the inspection, there was no nonslip mat located in the bathroom tub or anywhere in the bathroom. Bathtubs and showers shall have a nonslip surface or mat. To address the immediate issue not having a non-slip surface in the bathrooms, the primary responsibility will fall to the Supervisor (or designated staff member) with the following plan of correction. The root cause of the issue likely stemmed from a lack of clear guidelines in maintaining the home in the prolonged absence of the individual, which will be addressed with the new procedures and regular monitoring. 01/20/2025 Implemented
6400.171At the time of the inspection, there were two opened boxes of instant rice found in the cupboards that were not closed properly therefore not being stored in a manner to protect it from contamination.Food shall be protected from contamination while being stored, prepared, transported and served. At the time of the inspection, there were two opened boxes of instant rice found in the cupboards that were not closed properly therefore not being stored in a manner to protect it from contamination. These issues pose risks for contamination and cross-contamination, which can affect the safety and quality of the food. The root cause of these violations likely stems from a lack of adherence to proper food storage protocols and insufficient training on food safety practices, resulting in uncovered food items and improper storage methods. To address the immediate issue, the Supervisor (or designated staff member) will take responsibility for correcting the violations. The immediate corrective actions will include removing the items that were potentially contaminated due to improper storage. 12/20/2024 Implemented
SIN-00244608 Unannounced Monitoring 05/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(b)The medications listed in 167b were not reported to the department within 72 hours for individual #1. Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home. A medication error occurred where medications were administered properly but documented incorrectly, leading to a failure to report the incident promptly. The error was identified after receiving the (LIS) notification for this violation, prompting the belated entry of incident reports. Effective June 13, 2024, we are implementing a plan to enhance medication administration oversight by our medical coordinators. As part of this initiative, each morning, our medical coordinators will conduct a thorough review of Medication Administration Records (MARs) to ensure the accurate and proper administration of all medications. This daily review will include verifying that each medication has been administered according to prescribed protocols and that documentation is complete and accurate. Furthermore, our medical coordinators will diligently identify any documentation errors or medication errors that may have occurred. In the event of such discrepancies, they will promptly and accurately report these errors through our incident reporting system. 06/13/2024 Implemented
6400.167(b)Individual #1 's Medication administration record (MAR) had multiple documentation errors listed. Other was listed for medication on May 6th,which included Alcohol prep pads, amantadine 100mg am, amantadine 100mg 8pm, divalproex 500mg 8pm, Melatonin 3mg 8pm, Blood Glucose 4pm, one touch kit verio 8am, one touch kit verio 4pm, Prazosin HCL 1mg 8pm, Prazosin 2mg 8 pm, Propranolol 20mg 8am, propranolol 2omg 8pm, Quetiapine 300mg 8pm, and trazadone 100mg 8pm. On May 8th when he was in the hospital the medications are listed as administered with other indicated for the following medications. Alcohol prep pads, amantadine 100mg am, amantadine 100mg 8pm, divalproex 500mg 8pm, Melatonin 3mg 8pm, Blood Glucose 4pm, one touch kit verio 8am, one touch kit verio 4pm, Prazosin HCL 1mg 8pm, Prazosin 2mg 8 pm, Propranolol 20mg 8am, propranolol 2omg 8pm, Quetiapine 300mg 8pm, and trazadone 100mg 8pm.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.It appears that the utilization of the "Other" designation by staff, rather than specifying successful, refused, on leave or on home visit, may have led to errors and ambiguities within the Medication Administration Record (MAR) system. This practice resulted in a lack of clarity regarding which medications were administered, potentially compromising patient safety and treatment efficacy. Furthermore, inconsistencies in documentation practices between when the individual is in different care settings, such as those found in home versus hospital environments, have likely exacerbated discrepancies in MAR entries. Manager override comments were immediately placed on the MAR to clarify the descrepancies that resulted in this violation. 06/13/2024 Implemented
6400.167(c)The medications listed in violation 167b were not reported as an incident for individual #1.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).A medication error occurred where medications were administered properly but documented incorrectly, leading to a failure to report the incident promptly. The error was identified after receiving the (LIS) notification for this violation, prompting the belated entry of incident reports. Effective June 13, 2024, we are implementing a plan to enhance medication administration oversight by our medical coordinators. As part of this initiative, each morning, our medical coordinators will conduct a thorough review of Medication Administration Records (MARs) to ensure the accurate and proper administration of all medications. This daily review will include verifying that each medication has been administered according to prescribed protocols and that documentation is complete and accurate. Furthermore, our medical coordinators will diligently identify any documentation errors or medication errors that may have occurred. In the event of such discrepancies, they will promptly and accurately report these errors through our incident reporting system. 06/13/2024 Implemented
SIN-00243965 Unannounced Monitoring 05/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)A pungent odor was in the living area and entrance area during the physical site walk through. A musty odor was in the upstairs bathroom. Individual # 1's bedroom had a pungent odor during the physical site walk through.Clean and sanitary conditions shall be maintained in the home. The individuals in this home need education and reminders about hygiene practices and their effects. In order to remedy the immediate issue, the maintenance team scrubbed the carpeting immediately to ensure the odor was no longer present. Additionally, QLS decided to replace the flooring, and by 6/1/2024 the floors in Individual #1 bedroom will be replaced. A copy of the maintenance request for the flooring to be replaced is attached as Exhibit #8. 06/01/2024 Implemented
6400.67(a)The ceiling tile in the living room corner had liquid stains on it. Individual # 1 requested replacement.Floors, walls, ceilings and other surfaces shall be in good repair. The QLS Team as a whole will be responsible for correcting this issue. The maintenance team will repair the ceiling tile immediately and ensure that all surfaces are in good repair company wide. Staff members come from various backgrounds and may have different standards or interpretations of what constitutes acceptable conditions. Cultural differences, personal experiences, and training backgrounds can all influence perceptions of maintenance and repair standards. 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. 06/01/2024 Implemented
6400.81(i)Individual # 1's bedroom had broken blinds during the walk through.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. The individual in this home sometimes struggles with regulating his emotions effectively (something that is being worked on daily), leading to outbursts of anger, property destruction or frustration during periods of upset. QLS will make modifications to the individual's living environment, such as replacing blinds with more durable or sensory-friendly alternative, to mitigate the risk of property destruction during periods of upset. Quality Life Services, Inc. Maintenance Team will be responsible for overseeing the correction process in the future. QLS intends to install curtains in all bedrooms instead of blinds. By following this plan of correction, we aim to address the immediate problem of broken blinds and prevent future occurrences by implementing a more durable alternative and ensuring proper maintenance. 06/01/2024 Implemented
SIN-00239314 Renewal 02/21/2024 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was completed on 3/7/23, which is not three to six months prior to the license expiration or six to nine months after the last inspection.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
6400.22(d)(1)Individual #1's financial record was not current and up to date. The beginning balance for February 2024 did not match the ending balance for January 2024.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. 1. A plan to fix the immediate problem a. WHO: QLS Program Specialists b. WHAT: QLS Program Specialists will ensure that all financial records are correct and up to date. c. WHEN and HOW: By April 5th QLS will have conducted a thorough review of financial records. 04/05/2024 Accepted
6400.67(a)At the time of the 02/22/24 Inspection, the bedroom to the right of the stairwell had excessive dark brown staining on the carpet under the window.Floors, walls, ceilings and other surfaces shall be in good repair. 1. A plan to fix the immediate problem a. WHO: QLS Field Managers b. WHAT: QLS Field Managers will ensure that all floors, walls, ceilings and other surfaces shall be in good repair c. WHEN and HOW: By April 5th QLS will have two field managers hired and scheduled to inspect each of the homes in their entirety at least once a week. 04/05/2024 Accepted
6400.77(c)At the time of the 02/22/24 Inspection, there was no first aid manual in the first aid kit. A first aid manual shall be kept with the first aid kit.1. A plan to fix the immediate problem a. WHO: QLS Field Managers b. WHAT: QLS Field Managers will ensure that all first aid kits have a first aid manual c. WHEN and HOW: By 4/5/2024 QLS Field managers will have a first aid manual attached to each first aid kit. 04/05/2024 Accepted
6400.111(f)The fire extinguishers were inspected on 2/21/22 and not again until 3/20/23, outside of the annual timeframe. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. 1. A plan to fix the immediate problem a. WHO: QLS Compliance Director b. WHAT: Fire extinguishers will be inspected annually. c. WHEN and HOW: By 3/20/24 all fire extinguishers will be inspected 04/05/2024 Accepted
6400.141(c)(1)Individual #1's most current physical completed on 10/25/23 does not include a review of the individual's medical history.The physical examination shall include: A review of previous medical history. 1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator b. WHAT: Medical Histories will be attached to physical forms for physicians to review c. WHEN and HOW: By 4/5/2024 all medical histories will be attached to the physical forms for physicians to review. 04/05/2024 Accepted
6400.141(c)(11)Individual #1's most recent physical completed on 10/25/23 does not include what bloodwork is needed.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator b. WHAT: Blood work to be completed will be added to the physical form as a check box for the physician c. WHEN and HOW: By 4/5/2024 physical forms will be modified 04/05/2024 Accepted
6400.144Individual #1 is to have their blood sugar checked daily.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 b. WHAT: Health services shall be arranged c. WHEN and HOW: By 4/5/2024 tasks will be added to Carasolva to ensure that blood sugar is checked daily 04/05/2024 Accepted
6400.217Individual #1 signed a release on 7/25/23 that was set to expire in six months and was to be resigned. There was no updated release.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. 1. A plan to fix the immediate problem a. WHO: QLS Program Specialists b. WHAT: Ensure that all releases of information are up to date c. WHEN and HOW: By 4/5/2024 all release of information forms will be up to date and signed by the individuals 04/05/2024 Accepted
6400.32(d)At the time of the walkthrough, Individual #1 attempted to speak to the licensing rep. Staff #1 immediately snapped at Individual #1 and said "Stop talking. They are talking to me, not you."An individual shall be treated with dignity and respect.1. A plan to fix the immediate problem. a. WHO: QLS Training Coordinator, QLS Management b. WHAT: QLS Training Coordinator will ensure staff are trained, QLS Program Specialists will ensure to monitor the treatment of individuals via in person monitoring. c. WHEN and HOW: QLS Training Coordinator will ensure that all QLS employees are trained on the new policy (depicted below) by 4/5/2024. QLS Program Specialists will monitor the quality care of the individuals at least monthly. 04/05/2024 Accepted
6400.165(g)Individual #1's psych med reviews completed from 3/17/23 to 2/5/24 do not include the reason for prescribing the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator b. WHAT: A reason for medications be prescribed will be added to all psych forms c. WHEN and HOW: By 4/5/2024 a form will be added to all psych reviews that depict the reason for medications being prescribed 04/05/2024 Accepted
6400.213(1)(i)Individual #1 has a mother and two sisters that are not included on the demographic information. The court-appointed guardian with Advocacy Alliance is listed as the next of kin.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.1. A plan to fix the immediate problem a. WHO: QLS Program Specialists b. WHAT: Ensure the next of Kin is listed on all individuals¿ demographics c. WHEN and HOW: By 4/5/2024 an additional line for next of kin will be added to all demographics 04/05/2024 Accepted
SIN-00236941 Monitoring - Reported Incident 01/03/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)2 metal upright radiators were in the living room with no cover. An upright metal radiator was located in Individual # 1's bedroom with no cover. An upright metal radiator was in the upstairs bathroom uncovered.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. 1. A plan to fix the immediate problem a. WHO: QLS Management, Maintenance and Staff b. WHAT: QLS staff will be responsible for any damage to any protective measures from heat sources. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Maintenance will be responsible for ensuring all protective measures are put into place. 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. By 2/28/2024 all heat sources will have protective measures in place. 02/28/2024 Implemented
6400.64(a)The kitchen refrigerator had spill residue on the bottom shelf during the physical site walk through. The upstairs bathroom had towels and clothing laying on the floor during the physical site walk through.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
6400.67(a)Individual # 1's bedroom was missing a window curtain during the physical site walk through. A broken television was on the floor of Individual # 1's bedroom during the physical site walk through. The toilet in the upstairs bathroom was not working during the physical site walk through.Floors, walls, ceilings and other surfaces shall be in good repair. 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 in good repair. 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
6400.72(b)A screen was missing from the living room window, from the front of home the right facing window. Screens, windows and doors shall be in good repair. 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 screens, windows and doors are in good repair. 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
6400.77(b)The First Aid Kit did not contain scissors 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 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
6400.77(c)The First Aid Kit did not have a first aid manual during the physical site walk through. A first aid manual shall be kept with the first aid kit.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 Not Implemented
6400.80(a)There was ice on the front sidewalk during the physical site walk through. 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
6400.80(b)The Shed in the rear of the building has doors which are falling off and could not be closed. A Window screen was laying on ground to the right side of the house, facing the house. Cigaretted Butts were strewn on the grass lawn outside of the rear egress. A Coffee mug was on the ground outside of the rear egress. Fallen Leaves were gathered along the ground front of the building. 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
6400.82(f)There were not towels in the bathroom by the laundry area 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. 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 bathrooms have toilet paper, paper towels and soap. 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
6400.214(b)Individual # 1's current Physical Examination, Assessment and ISP were not at the home during the physical site walk through. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential 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 Implemented
6400.216(a)Individual # 1's Program binders containing Financial information and Personally identifiable information was found on the kitchen table unlocked during the physical site walk through. An individual's records shall be kept locked when unattended. 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 records are locked in all 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
SIN-00142293 Renewal 09/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)In the attic there was a very large amount of small rodent feces on an old stained twin size mattress.There may not be evidence of infestation of insects or rodents in the home. It is important that QLS homes be free of any infestation. There were possible signs of a small rodent infestation in the attic of one of the individual¿s homes. The attic previously was inaccessible and not checked regularly. Terminix was contacted to conduct an inspection of the home, and on September 11, 2018 the mattress was removed and disposed of and the feces were cleaned up. The Field Manager inspects this area of the home weekly to ensure that there aren¿t any new signs of infestation as we are working with Terminix to ensure there is no infestation. The Operations Manager will inspect the homes periodically multiple times a year to make sure that the homes are being maintained in good condition and clear of infestation. The operations department will document each home inspection with an already existing house inspection form. 09/11/2018 Implemented
SIN-00270550 Unannounced Monitoring 07/24/2025 Compliant - Finalized
SIN-00261458 Unannounced Monitoring 02/27/2025 Compliant - Finalized
SIN-00195757 Renewal 11/30/2021 Compliant - Finalized
SIN-00180455 Renewal 12/07/2020 Compliant - Finalized
SIN-00117522 Renewal 08/16/2017 Compliant - Finalized
SIN-00076080 Renewal 03/17/2015 Compliant - Finalized
SIN-00067747 Initial review 08/28/2014 Compliant - Finalized