Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00272633 Renewal 08/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 has been prescribed medications to treat symptoms of psychiatric diagnosis Individual #1 had a psychotropic medication review on 08/26/24, and then again on 12/17/24. This exceeds the at least every 3-month requirement. Individual #1's psychotropic medication reviews completed on 12/17/24, 01/07/25, 02/11/25, 06/05/25, and 07/31/25 did not include the frequency for medications Celexa 20 ML, Melatonin 6 MG, and Guanfacine 2 MG.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.Mainstay Life Services understands that 6400.165(g) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. 09/16/2025 Implemented
6400.181(f)Individual #1's most recent ISP planning meeting was conducted on 02/20/25. There is no documentation that Individual #1's current assessment was provided to the plan team members at least 30 calendar days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Mainstay Life Services understands that 6400.181(f) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. 10/01/2025 Implemented
6400.195(b)Individual #1 has a restrictive procedure plan and the Human Relations Team reviewed the plan on 09/15/24, and then again on 04/22/25. This exceeds 6 months between reviews. [Repeat violation 9/4/24 et. al.]The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.Mainstay Life Services understands that 6400.195(b) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. 10/01/2025 Implemented
SIN-00267277 Unannounced Monitoring 04/17/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(d)Individual #1's Individual Support Plan (ISP), last updated on 05/22/25, states in The Supervision Care needs section under both Home and Community Supervision "2:1 staffing up to 24 hours per day" and intensive supervision required in this setting is indicated as yes in both areas. In Reason for intensive staffing, the plan for reducing Intensive staffing supports indicates that 2:1 is not able to be reduced at this time. On 04/13/25 at 5:30 PM, only one staff was present with individual, which does not meet the 2:1 staffing as required by ISP.The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ).Individual #1 will be staffed 2:1 starting immediately upon his/her return home to the program site due to medical issues (started on 5/28/2025). 06/30/2025 Implemented
6400.45(e)On 04/17/25 at 3:20 PM, Direct Service Worker #1 stated that while working with individual #1 alone, that the staff person went out the front door of the home for the purpose of re-entering the home from the kitchen door, leaving Individual #1 unsupervised.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.Individual #1 will be staffed 2:1 starting immediately upon his/her return home to the program site due to medical issues (started on 5/28/2025). 07/31/2025 Implemented
6400.186Individual #1's Individual Support Plan (ISP), last updated on 05/22/25, states in The Supervision Care needs section under both Home and Community Supervision "2:1 staffing up to 24 hours per day" and intensive supervision required in this setting is indicated as yes in both areas. In Reason for intensive staffing, the plan for reducing Intensive staffing supports indicates that 2:1 is not able to be reduced at this time. On 04/17/25 at 3:20 PM, Direct Service Worker #1 stated that they were working alone with the individual on 04/13/25.The home shall implement the individual plan, including revisions.Individual #1 will be staffed 2:1 starting immediately upon his/her return home to the program site due to medical issues (started on 5/28/2025). 06/30/2025 Implemented
SIN-00251390 Renewal 09/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's assessment, completed on 04/12/24, indicated the following regulations were not applicable: 6400.32a thru 6400.34b, 6400.42 thru 6400.51a, 6400.151a thru 6400.152c, 6400.161a thru 6400.186, and 6400.211 thru 6400.217. Therefore, the self-assessment was not complete [Repeat violation 9/8/23, et. al and 9/21/22, et. al.].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. All Mainstay Life Services licensed residential managers and coordinators (management staff) will complete a training on how to complete the self-assessments to meet the compliance standards. This will include what fields cannot be marked as "NA," and what needs to happen when something is found to be in violation. This training will take place by February 28th, 2025, and will be measured by the use of a sign-in sheet (who attended the training), as well as a description of the training including learning objectives (what was discussed). The reason the training will occur in February is the self-assessments are done in March, so this will be a good time to review the requirements of the self-assessments. 02/28/2025 Implemented
SIN-00069648 Renewal 09/10/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)The three month review for Individual #1 dated 8/8/14 did not include the reason for prescribing the medication and the necessary dosage. The three month review for Individual #1 dated 5/8/14 did not include the necessary dosage. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Documentation was obtained from Western Psych on 9/11/2014. The manager was retrained on 9/16/2014. Documentation will be forwarded to verify training. The program coordinator will review paperwork after each psychological to assure it has been correctly completed. 11/07/2014 Implemented
6400.213(13)The record for Individual #1 did not include a psychological evaluation. Individual #1 is being treated for Impulse Control disorder, NOS.Each individual's record must include the following information: Copies of psychological evaluations, if applicable. Psychological was obtained on 9/11/2014 from the SC. Our quality assurance coordinator is currently auditing all records to assure psychologicals are present for all individuals served. Audit was completed on 10/6/2014. This item will be included in our rolling record review. 11/07/2014 Implemented
SIN-00230513 Renewal 09/06/2023 Compliant - Finalized
SIN-00179476 Renewal 11/17/2020 Compliant - Finalized
SIN-00119665 Renewal 08/14/2017 Compliant - Finalized