Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258355 Unannounced Monitoring 01/08/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The back steps which is an exit for fire drills was not shoveled at the time of the inspection. Outside walkways shall be free from ice, snow, obstructions and other hazards. he residential staff will be responsible for ensuring that snow and ice removal procedures are followed for all fire exits and sidewalks, especially when vehicles are grounded due to inclement weather. The On Call Managers will oversee the notification process to staff regarding vehicle grounding and snow removal requirements. The immediate correction involves ensuring that when vehicles are grounded due to inclement weather, notification will be sent out to all staff, and a reminder will be issued to shovel all fire exits and sidewalks to ensure safety and accessibility. Immediate Action: When vehicles are grounded due to inclement weather, the On Call Manager will send an immediate notification to all relevant staff. This notification will include a reminder to shovel all fire exits and sidewalks. 02/06/2025 Implemented
SIN-00251709 Unannounced Monitoring 09/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the inspection, there was water draining out of the wall onto the basement floor.Floors, walls, ceilings and other surfaces shall be in good repair. The inspection revealed that water was draining out of the wall onto the basement floor, indicating a potential issue with water management and structural integrity. To address this problem, we will implement a plan of correction that includes the addition of basements to the existing interactive checklist by 10/31/24. 10/31/2024 Implemented
6400.214(a)Individual #1's records where not at the home at the time of inspection.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home."The issue identified is that current copies of record information required in § 6400.213(2)-(14) are not being maintained at the residential home, which poses a risk of potential non-compliance with regulatory standards. To address this, the objective is to ensure that all required record information is updated and readily accessible in an electronic format at the residential home, in full compliance with regulations. 01/01/2025 Implemented
SIN-00241911 Unannounced Monitoring 03/28/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There is a single floor tile in the upstairs bathroom that is not grouted down. The tile is able to be completely lifted up off of the floor. Floors, walls, ceilings and other surfaces shall be free of hazards.Preventing hazards and maintaining the safety of the individuals and staff members is very important to the Management Team at QLS. 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. We employee a diverse group of employees that come from many different walks of life and what are acceptable conditions to one could be viewed as unacceptable by another. The loose tile has been repaired and a picture of the repair is being forwarded to you as Exhibit #2. 05/10/2024 Implemented
6400.107A portable space heater (electric plug-in fireplace) was in the living room at the time of the inspection.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. Individuals having a non-institutional, homelike environment is very important to the Management Team of QLS. At times when individuals have spend down monies it is their desire to purchase a fireplace or fireplace/entertainment type piece of furniture as many of them find them relaxing. It was oversight by QLS management that fireplaces would be disallowed per this regulation as they aren¿t portable, but management failed to take into consideration that they aren¿t hardwired in as required by the regulation. The fireplace in violation of this regulation has been since removed from the home and all other licensed homes have also been cleared of any fireplaces. 05/10/2024 Implemented
6400.144Individual #1's March 2024 Medication Administration Record (MAR) listed the following PRN medications which were not available in the home: Benzonatate cap 100mg, Diphen/Atrop Tab 2.5mg, Amonium Lactate 12% cream, Hydocortiso Cream 2.5%, Alcohol Prep Pad 70%, Prochlorper tab 10mg, Ibuprofen tab 600mg, Loratadine tab 10mg.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 PRN¿s 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
6400.216(a)Individual #1's records were found unlocked in the staff office. An individual's records shall be kept locked when unattended. Protection of an individual¿s personal information is very important to the Management Team at QLS. In meeting with staff members, it was determined that at times there are events that take place that cause them to abruptly leave the office area of the home, at times failing to ensure that the door is shut and locked. In an attempt to alleviate this concern, each staff office door was equipped with automatic door closers and have had an autolocking doorknob installed. Pictures of these installed devices are attached as Exhibit #6. 05/10/2024 Implemented
6400.163(d)At the time of the inspection, the following PRN medications were found unlocked: Anti-Diarrhea tab 2.5mg, Hydrocortisone Cream 2.5%, Triamcinolon Cream 0.1% (There was no lock on the medication box and the staff office where the medication was found, was also unlocked).Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Proper storage of the individual¿s medication is necessary in ensuring the individuals health and safety. In meeting with staff members, it was determined that at times there are events that take place that cause them to abruptly leave the office area of the home, at times failing to ensure that the door is shut and locked. In an attempt to alleviate this concern, each staff office door was equipped with automatic door closers and have had an autolocking doorknob installed. All medication boxes have been relocated to the staff office, should one be available to ensure that they are always secure, even in the event of an unexpected emergency. 05/10/2024 Implemented
SIN-00237102 Unannounced Monitoring 01/03/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)Individual #1 has a diagnosis of cerebral palsy. Individual #1 refuses to utilize a gait belt and doctor's have identified that the Individual is unsafe with the use of a walker because they believe it may be used as a weapon. Throughout their home, Individual #1 was observed to require staff assistance while ambulating by always holding on to them. The only time staff did not assist in ambulation was when Individual #1 was descending the stairs, where a railing was used. The front exit of Individual #1's home has 3 steps leading out to the yard. Additionally, Individual #1's bedroom and the only bathroom is located on the second floor of the home. There are no grab bars to assist the individual in ambulating throughout the home and due to unsteadiness and physical disability present, there is not appropriate accommodations made to ensure the safety and movement within the home as well as entering and exiting the home.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. 1. A plan to fix the immediate problem a. WHO: QLS Management b. WHAT: QLS Management will relocate individual¿s or provide reasonable accessibility as per this regulation c. WHEN and HOW: On 2/1/2024 this individual was relocated to a home that has a bedroom, bathroom, kitchen and living room on the first floor as well as a accessible entrance. 02/02/2024 Not Implemented
6400.77(b)First aid kit contents did not contain scissors. 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. 4. 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
6400.81(k)(3)Individual #1's bed pillows did not have pillowcases on them.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.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 individuals have Bedding, including pillow, linens, and blankets appropriate for the season. QLS management will be responsible for weekly home inspections, including an inspection of the individual¿s rooms. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly. 2. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections and purchased any replacements that are needed. 02/02/2024 Not Implemented
6400.141(c)(14)Individual #1's current physical dated 10/19/2023 does provide medical information pertinent to medical diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. 1. A plan to fix the immediate problem. a. WHO: QLS Medical Coordinator b. WHAT: QLS Medical Coordinator will ensure that all physical examinations are completed and fully documented within 12 months c. WHEN and HOW: QLS Medical Coordinator developed a tracking system on 2/1/2024 to ensure that all physicals were completed annually for each individual. On 2/1/2024 the physical form was updated to include specific questions regarding information pertinent to medical conditions and diagnosis for the physician to answer to ensure compliance with this regulation. 02/02/2024 Implemented
6400.144Per Individual #'1s current ISP dated 9/20/2023 and prescription order dated 11/20/2023, Individual's blood glucose should be checked 4 times a day; before meals at 8am, noon, 4pm, and 7pm. Upon review of Individual #1's December 2023 blood glucose tracking sheet, it was discovered that there were 11 times where it was not recorded what the sliding scale insulin dose was that was given to Individual #1. In January 2024, there were 2 occasions (1/1/2024, 1/2/2024) where insulin dose that administered was not recorded during the 7pm time slot.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 available in the home to the individuals at all times. 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
6400.181(e)(4)It was observed during the inspection that alarms are installed on stairs leading from the living room to the upstairs, which is where the individual's bedroom and bathroom are located. There is no mention of this additional need for supervision in the Individual's current assessment dated 11/15/2023. The assessment must include the following information: The individual's need for supervision. a. WHO: QLS Program Specialist b. WHAT: QLS Program Specialist will ensure that each record contains the individual¿s annual assessment and that the assessment includes all the required information to remain in compliance with the regulation. c. WHEN and HOW: On 2/1/2024 QLS Program Specialist will update all individuals¿ records including their assessment and ensure compliance with this regulation. 02/02/2024 Implemented
6400.213(6)Individual #1's most current assessment made available in the home in both paper and in electronic format at the time of the inspection was dated 11/15/2022. However, the most recent assessment provided by the office is dated 11/15/2023. Most current is not available to staff working in the Individual's home.Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment). 1. A plan to fix the immediate problem. a. WHO: QLS Program Specialist b. WHAT: QLS Program Specialist will ensure that each record contains the individual¿s annual assessment. c. WHEN and HOW: On 2/1/2024 QLS Program Specialist will update all individuals¿ records including their assessment. 02/02/2024 Implemented
6400.167(a)(3)Prescription order dated 11/30/2023 for Individual #1's HumaLOG Kwikpen 100 units/ML injectable solution states the following protocol for before bedtime snack dose (7pm): if blood sugar is 70--120 = None, 120-180 = 1u, 180-220 = 2u, 221-270 = 3u, 271--320 = 4u, 321--370 = 5u, 371--420 = 6u, 421--470 = 7u. Insulin dosage reviewed for Individual #1 on December 2023 tracking sheet shows that the wrong insulin dosage was given on 12 occasions.Medication errors include the following: Administration of the wrong dose of medication.1. A plan to fix the immediate problem. a. WHO: QLS Management and Staff b. WHAT: QLS management input all medication errors into the EIM system c. WHEN and HOW: On 2/1/2024 all medication errors were entered into the EIM system. 02/02/2024 Not Implemented
6400.182(c)· Individual #1's current ISP, dated 9/20/2023 states that a new gait belt was ordered, and they are willing to utilize it. However, based off the assessment dated 11/15/2023, it states that the Individual refuses to wear the gait belt. The gait belt was not found in the home during the inspection. The ISP has not been updated to reflect the current assessment which identifies that the Individual refuses to wear the gait belt. · Individual #1's current ISP, dated 9/20/2023 states that they are recommended to wear diabetic shoes, however they choose not. Diabetic shoes were not located within the home. There is no documentation that although Individual #'1 chooses not to wear the shoes, that they also no longer have them or have access to them.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 Not Implemented
6400.186Individual #1's current ISP, dated 9/20/2023 states that knives are locked in the home due to prior threats to harm themselves or others. At the time of the inspection, sharps were found unlocked in a box located inside the unlocked staff office. An additional small, serrated edge knife was found in an unlocked closet off the living room.The home shall implement the individual plan, including revisions.1. A plan to fix the immediate problem. a. WHO: QLS Management and Staff b. WHAT: QLS Program Specialist will ensure that all revisions to the individual plan are made available for staff immediately via the online database and update the individual binder within the home. QLS Program Specialists will monitor that all plans are being implemented. QLS Staff will review any revisions and sign off that they have read and understand them as well as begin implementing the changes. c. WHEN and HOW: QLS Medical Coordinator will ensure all homes have received training on any and all medically related restrictions, recommendations, practices for each individual. QLS Behavior Specialist will ensure that staff are trained on all behavioral support plans, restrictions, non-restrictive environmental adaptations. QLS Program Specialists will ensure that all staff are trained on the individual plans and are implementing them by conducting weekly audits of documentation in the homes. QLS management will be conducting weekly house inspections to ensure compliance with this regulation. 02/02/2024 Implemented
SIN-00230671 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1's financial record was listed for 1.36 but had 2.36 in cash.(2) Disbursements made to or for the individual. 1. A plan to fix the immediate problem a. WHO: QLS Staff b. WHAT: QLS staff will be responsible for completed the ¿Daily Tasks to be Completed document that includes Verify/Count Consumer Funds c. WHEN and HOW: On 9/21/2023 the updated Daily Tasks to be Completed¿ document was provided to QLS company wide, with a memo explaining how to utilize it. 09/21/2023 Implemented
SIN-00212791 Renewal 10/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff # 2 had a physical examination on 06/18/19 and not again until 07/12/21. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. QLS management will be responsible for ensuring that all staff are in compliance with their initial and then biennial physicals. On 10/13/2022 there was a policy developed for QLS employees and management in regard to the regulation of staff physicals. All Quality Life Services, Inc employees who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. 10/13/2022 Implemented
6400.151(c)(2)Staff # 2 had a TB test on 06/20/19 and not again until 02/18/22. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. QLS management will be responsible for ensuring that all staff are in compliance with their initial and then biennial Tuberculin Testing. On 10/13/2022 there was a policy developed for QLS employees and management in regard to the regulation of Tuberculin testing. a. QLS management will provide any new hires with the appropriate documentation for their initial Tuberculin testing. Upon completion of the testing QLS management will review the documentation to ensure that everything is in compliance prior to the start of training. 10/13/2022 Implemented
SIN-00182244 Renewal 01/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature at the time of the inspection measured in individual #1's bathroom was 122.6 Hot water temperatures in bathtubs and showers may not exceed 120°F. § 6400.68. Running water. (b) Hot water temperatures in bathtubs and showers may not exceed 120°F. 1. A plan to fix the immediate problem a. WHO: Maintenance and Field Managers b. WHAT: The QLS Inc. Maintenance department will assure every house has their hot water tank set at 115 degrees Fahrenheit. Field Managers will check the water temperature virtually once a month with the house staff until they can go to the houses in person. c. WHEN and HOW On 2/2/2021 the maintenance department began going to each house to assure the hot water tank was set at no more than 115 degrees Fahrenheit. Field managers will continue to do their virtually monthly inspections that will now include checking the hot water temp with the staff on shift. If the hot water exceeds 118 degrees Fahrenheit, they will submit a maintenance request to the maintenance department. The maintenance department will respond immediately upon receipt of the maintenance request. They will then lower the hot water tank to assure health and safety. 2. A plan to prevent future occurrences The hot water tanks will remain at 115 degrees Fahrenheit. Field managers will monitor the hot water monthly during their virtual check ins. Once they can go in person, they will then check the hot water themselves at each house on a monthly basis as well. The hot water is also currently monitored on the fire drills and checked on a weekly safety check list. 3. Training: All QLS Inc. staff have been made aware of this citation and they have been trained on how this role will impact their job duties. They have been trained via the Memo that has been distributed to the houses on 2/4/2021 via email 4. Attachments #1- email sent on 2/4/2021 #2- Memo from email attachment #3- copy of the new hot water temp tracking for field managers- excel spreadsheet 02/04/2021 Implemented
6400.32(p)Individual #1 rights did not include a choice of roommate listed on the sign off.An individual has the right to choose persons with whom to share a bedroom.§ 6400.32. Rights of the individual. (p) An individual has the right to choose persons with whom to share a bedroom. 1. A plan to fix the immediate problem a. WHO: Office Manager b. WHAT: Compliance Policy 0021 was created in response to this citation. c. WHEN and HOW On 2/2/2021 Compliance Policy 0021 was created On 2/4/2021 Compliance policy 0021 was published to all QLS Inc. staff, managers, and individuals supported. Everyone is now made aware that QLS Inc. has a policy stating that people supported by QLS Inc. will never be required to share a bedroom. This in turn excludes 6400.32 (p) from the individual rights. 2. A plan to prevent future occurrences All current employees have been made aware of Compliance policy 0021 and all future employees will be made aware of this policy when they review the policy and procedures in orientation. 3. Training: All QLS Inc. staff have been made aware of this citation and they have been trained on how this role will impact their job duties. They have been trained via the Memo that has been distributed to the houses on 2/4/2021 via email. 4. Attachments #1- email sent on 2/4/2021 #2- Memo from email attachment #4- Copy of Compliance Policy 0021 02/04/2021 Implemented
SIN-00162691 Unannounced Monitoring 08/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)Per discussions with the operations manager, Staff #1, during the 8/9/19 onsite inspection, Quality of Life residential management staff were first made aware of staff working in the home receiving a bite, assumed to be by a bed bug, on 7/30/19 at this home. Staff #1 contacted Terminix on 7/30/19 about inspecting the home and followed up via text message on 8/1/19 to inquire about the inspection of the home. However, Staff #1 did not receive any notification from Terminix of the results of the inspection and did not attempt to contact Terminix via text message again until 8/5/19. At that point, Terminix staff confirmed they did not inspect the house yet and would try to inspect in the follow week. On 8/6/19, Terminix staff confirmed via text message with a picture of a "bed bug casing where the nurses sit, Barr Ave." At this point, the agency has left the staff and individual's susceptible to additional bed bug bites and infestation for one week. On 8/6/19 Terminix staff also texted Staff #1, "I am going to recommend a 90 day on the blue house (Barr Ave)." There is no documentation from the professional exterminator to indicate the treatment recommended, the schedule to be followed with treatment, steps for staff to follow during treatment, when treatment was started, or that a professional exterminator had initiated any treatment at the home yet at the time of the unannounced visit on 8/9/19.There may not be evidence of infestation of insects or rodents in the home. On August 9, 2019 during the announced inspection QLS Operations Manager contacted Terminix and made their owner aware of the escalated nature of the situation. Terminix was able to get an inspector and treatment technician out to inspect the homes that were awaiting inspection and to treat the home noted above. Please see Exhibit #1 - Account Invoice as proof that this home was serviced on August 9, 2019. QLS has developed a Policy and Procedure for the Treatment of Bed Bugs, attached as Exhibit #2 as well as a Bed Bug Encounter Log, attached as Exhibit #3 that will be completed by the assisting manager for the encounter and overseen by the Administrative Assistant. The log will capture time sensitive data and ensure that the individuals health and safety are being taken into consideration and that the process is being monitored closely. In the event of a lag in communication with the Terminix Inspector or Treatment Technician immediate action will be taken and noted. Furthermore, a meeting is being scheduled between our Management and Terminix to review the policy and the level of service response time that is required. 09/23/2019 Implemented
SIN-00142257 Renewal 09/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was a missing knob on the top drawer of the small dresser in individual #1's bedroom.Floors, walls, ceilings and other surfaces shall be in good repair. It is important to ensure the individuals home is in good repair. Individual #1¿s small dresser was missing knob on the top drawer. This occurred from every day use and staff failing to write up the issue. We had the stand repaired on September 25, 2018 and Attachment #22 is a picture of the repaired stand. The Field Manager and Maintenance Department have been provided Maintenance Repair Orders that they are to complete while out in the field. It was always prior practice that when they were in the home and seen an item that needed repaired that they would have the direct care staff write it up. Moving forward they will write the issues that they notice during home inspections themselves. The Operations Manager will inspect the homes periodically multiple times a year to make sure that the homes are being maintained in good condition. The operations department will document each home inspection with an already existing house inspection form. During the management meeting on October 25, 2018 it will be reviewed with all direct care staff the expectations of a maintaining home in good repair. 09/25/2018 Implemented
6400.74There was no non skid surfaces on the basement steps.Interior stairs and outside steps shall have a nonskid surface. It is important to ensure the health and safety of all the individuals that we support. There were no non-skid surfaces on the basement steps. The basement steps are inaccessible direct care staff and individuals, so it was not reported. Non-skid strips were applied to the basement steps on September 25, 2018 and a photo of the repairs are attached as Attachment #21. The Field Manager and Maintenance Department have been provided keys to the inaccessible areas of the homes as well as they have been provided Maintenance Repair Orders that they are to complete while out in the field. It was always prior practice that when they were in the home and seen an item that needed repaired that they would have the direct care staff write it up. Moving forward they will write the issues that they notice during home inspections themselves. The Operations Manager will inspect the homes periodically multiple times a year to make sure that the homes are compliant with the regulations. The operations department will document each home inspection with an already existing house inspection form. 09/25/2018 Implemented
6400.216(a)Repeat from 8/16/17: Individual #1's personal information was kept unlocked in the spare bedroom. Incidents reports, what you need to know document, and ER discharge paperwork. An individual's records shall be kept locked when unattended. It is important for all individual records to be kept locked when unattended because it is important to keep an individual¿s records confidential. The staff office was unlocked and there was individual¿s personal information that was not secured. This violation occurred as an oversight by QLS direct care staff and management due to them believing there was no confidentiality issue because it was a 1-person home. Upon the licensers exiting meeting on September 14, 2018 the home that was found to be out of compliance with this regulation was contacted by their Program Specialist and informed that the office needed to be secured immediately. On September 17, 2018 an agency wide memo was issued by the Operations Manager educating staff that all individual records, schedules and staff note books are required to be kept in the designated locked areas. This memo is being forwarded to you as Attachment #1. The week of September 17, 2018 the Field Manager inspected every location ensuring that all staff offices were locked. During the company wide meeting scheduled for October 25, 2018, all direct care staff will be educated on the importance of locking personal information. Furthermore, the Field Mangers checklist of regulatory items was revised to include these specific items, which is being forwarded to you as Attachment #2. The Field Manager is responsible for unannounced inspections of each residential location multiple times a month. The Field Managers Checklist will be reviewed weekly by the Operations Manager to see which areas we are lacking compliance in, so an internal corrective action can be implemented and/or revised. There was also a management meeting held on September 18, 2018 in which this citation was reviewed with the managers and they were instructed to be more vigilant while out at the homes to ensure compliance with this regulation. Attached as Attachment #3 is the September 18, 2018 Management Meeting Agenda. 09/18/2018 Implemented
SIN-00265919 Unannounced Monitoring 05/06/2025 Compliant - Finalized
SIN-00175768 Unannounced Monitoring 09/01/2020 Compliant - Finalized
SIN-00160797 Renewal 10/23/2019 Compliant - Finalized
SIN-00117523 Renewal 08/16/2017 Compliant - Finalized
SIN-00076081 Renewal 03/17/2015 Compliant - Finalized
SIN-00071755 Initial review 11/25/2014 Compliant - Finalized