Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262290 Unannounced Monitoring 03/06/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the inspection (3/6/2025), there was a golf ball size amount of lint found in the dryer trap. Floors, walls, ceilings and other surfaces shall be free of hazards.The issue of lint buildup in the dryer trap occurred due to: Inconsistent Adherence to Procedure: While there have been guidelines in place regarding lint trap cleaning and removal after each load, they were not strictly followed by the residential support staff. 1. A Plan to Fix the Immediate Problem a. WHO: Maintenance team b. WHAT: Install an automatic lint trap contraption. c. WHEN and HOW: ¿ When: Effective 4/9/2025 How: QLS has installed a contraption that automatically pulls the lint trap out when the dryer door is opened, serving as a visual reminder for staff to clean the lint after each load of laundry. Supervisors will verify compliance with the staff of their homes. 04/09/2025 Implemented
6400.166(b)On 3/6/2025 The Department observed Staff #1 recording all 8am medication administrations at approximately 9:15am for Individual #1. Staff #1 reported that medications were in fact administered at 8am. However, the medications were not recorded on the Medication Administration Record until approximately 9:15am.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The issue of late medication documentation occurred due to: 1. Staff #1 administered medications on time but delayed documentation, leading to potential errors or discrepancies. Staff may have been sidetracked with other responsibilities, causing a delay in recording the administration. 1. A Plan to Fix the Immediate Problem a. WHO: QLS Management Staff #1 b. WHAT: ¿ Retrain Staff #1 on the importance of immediate documentation after medication administration. c. WHEN and HOW: When: by 4/9/2025 How: Staff #1 will receive retraining by the QLS management on proper documentation. As well as receive disciplinary action for non-compliance with medication administration protocols. 04/09/2025 Implemented
SIN-00253487 Unannounced Monitoring 10/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the kitchen sink was 133.5 degrees Fahrenheit during the physical site walk through. Hot water temperatures in bathtubs and showers may not exceed 120°F. The QLS Maintenance Team, Feild Managers, and residential staff will be responsible for correcting this issue. The maintenance team has addressed the high water temp at this location by adding a mixing valve to ensure the temperature does not exceed 120 degrees company-wide to prevent from accidental scalding. One of the biggest challenges is getting staff members to identify and report hazards to the extent that is required by regulation, which is the root cause of this violation.We will implement more consistent training to all staff and management; along with implementation of Connecteam Launch Pad. This is an interactive system that provides a more effiecient way to track maintenance work lists and issues. 12/15/2024 Implemented
SIN-00239322 Renewal 02/21/2024 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self- assessment for this home was completed on 3/6/2023 and this date is not within 3-6 months prior to the license expiration date (11/2023-2/2024) or 3-6 months after last licensing (5/2023-8/2023).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
6400.15(c)The self-assessment for this home indicated a violation for regulation 52c1, however there was no written description and no written summary of corrections attached.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. 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
6400.67(a)Individual #1's bedroom had a soft ball sized chipped paint hole on the wall to the right of the clothes closet.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(b)At the time of the inspection, the first aid kit did not contain an assortment of bandages. The bandages that were in the first aid kit were all the same size. 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 Field Managers b. WHAT: QLS Field Managers will ensure that all first aid kits have an assortment of bandages c. WHEN and HOW: By 4/5/2024 QLS Field managers will have all first aid kits stocked with adequate supplies 04/05/2024 Accepted
6400.141(c)(6)Individual #1's most recent physical dated 1/23/2024 documented that the most recent TB was given on 1/23/2024 and read on 1/25/25. The physical was not checked for accuracy and therefore this documentation error was not caught.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. 1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator b. WHAT: Rectify the documentation error by updating Individual #1's medical records to reflect the accurate dates of the TB test administration and reading. c. WHEN and HOW: By 4/15/2024 all physicals will be reviewed for accuracy 04/05/2024 Accepted
6400.216(a)There was a filing cabinet in the living room that was unlocked at the time of the inspection that contained personal information of an individual (individual #2) who no longer lives at this home; the individual moved to another home location within the company. An individual's records shall be kept locked when unattended. 1. A plan to fix the immediate problem a. WHO: QLS Field Managers b. WHAT: All information will remained locked in the homes c. WHEN and HOW: By 4/5/2024 all individual¿s information will be locked in the homes 04/05/2024 Accepted
6400.165(e)At the time of the inspection, Individual #1's prn medication list included, "Diclofenac Gel 1% (for Voltaren), this medication was not in the home at the time of the inspection. This PRN medication was ordered on 8/17/2021, however Staff #1 stated that the medication was discontinued since 2022, however there was no written notice of this change, and the medication record/PRN list was not updated to reflect this change.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator b. WHAT: All medications will be listed on the MAR and changes will be reflected on the MAR c. WHEN and HOW: By April 5th, all medications will be audited and corrected to be listed on the MAR 04/05/2024 Accepted
6400.167(a)(1)Individual #1 is prescribed "Synjardy XR Tab 5-1000mg". On 2/12/24 and 2/13/24 the MAR indicated "on hold" due to being "out of the medication" thus individual was not administered the medication on those two days. This medication is not automatically filled by the pharmacy; therefore, staff should be aware of when the medication is getting low to reorder the medication so that it arrives in time so there is no lapse in the medication.Medication errors include the following: Failure to administer a medication.1. A plan to fix the immediate problem a. WHO: QLS Medical Coordinator b. WHAT: Medication Errors will be entered for the 2 days that this medication was not given c. WHEN and HOW: By April 5th all medication errors will be entered, and all medications will be ordered to prevent future occurrences. 04/05/2024 Accepted
6400.182(c)Individual #1's most recent ISP dated 12/28/2023 indicates "No known Allergies" however the demographic sheet, the Lifetime medical history attached to the annual assessment (dated 1/30/24), and the Physical dated 01/23/2024 indicates that individual #1 has allergies to Penicillin, Pure chocolate, no "Tussin" syrup (per Dr. Koban), and seasonal allergies.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: All ISPs will be updated c. WHEN and HOW: By April 5th all ISPs will be updated and reflect accurate and current information 04/05/2024 Accepted
SIN-00236948 Monitoring - Reported Incident 01/03/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The basement bathroom had clumps of dirt all over the floor and in the shower. The toilet and sink were covered in dirt as well. Also, individual #1's bedroom door was very dirty in high touch point areas.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 door had a crack and what appeared to be a previously repaired hole in it.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
6400.67(b)At the time of the inspection there was a hole in the basement floor where a sump pump was previously placed per staff #1. There was a grate to cover this hole lying on the floor next to the hole however it was not covering the hole. Also in the basement, there was a black substance on the wall ( to the left once at the bottom of stairs) that appears to be mold. Floors, walls, ceilings and other surfaces shall be free of 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 all floors, walls, ceilings and other surfaces 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
6400.144Per the ISP, individual #1 is prescribed an 1800 calorie ada low sodium/low cholesterol diet. At the time of the inspection on 1/3/24, there was daily meal logs tracking individual #1's meals however the caloric intake is not being tracked, therefore it is unable to be determined if the prescribed diet is being accurately followed. Per the ISP, individual #2 is prescribed a 1500 calorie. There are daily meal logs being kept but again the caloric intake is not being tracked, therefore it is unable to be determined if the prescribed diet is being followed.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 Not Implemented
6400.214(b)At the time of the inspection on 1/3/24 there was no copies of the current ISP or assessment at the home. Staff #1 indicated the ISP and assessment is available electronically on Carasol. Staff #1 was unable to show that these documents were, in fact, available on Carasol. 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 Not Implemented
6400.163(h)At the time of the inspection on 1/3/24, individual #2's PRN of Acetaminophen 325mg had expired on 12/19/23 and there was no other acetaminophen available for the individual.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.1. A plan to fix the immediate problem. a. WHO: QLS Medical Coordinator, management and Steff b. WHAT: QLS Medical Coordinator will ensure all medications are stored properly and disposed of properly if necessary. QLS management will inspect the medication storage weekly during unannounced inspections. QLS staff will ensure proper storage/disposal daily of medications.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: QLS Medical Coordinator will ensure that all homes are equipped with all PRNs prescribed and with a locked medication box, and instructions for disposing of refused, expired or discontinued medications by 2/1/2023. 02/02/2024 Implemented
6400.166(a)(2)For individual #2, the biotene specially formulated toothpaste on the MAR had no presriber listed. The medication buspirone lists on the label but on the MAR. For individual #2, Lexapro and Neurontin lists on the medication labels but on the MAR. For individual #1, the medication Act Total 0.5% lists Dr. on the medication label and Dr on the MAR.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-00142297 Renewal 09/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The front porch screen on the screen door contained approximately a one and a half foot long rip down the left side of the screen. Screens, windows and doors shall be in good repair. It is important to ensure the individuals home is in good repair. The front porch screen on the screen door was ripped. This occurred from every day use and staff failing to write up the issue. The porch screen was repaired on September 28, 2018 and a picture of the repair is being forwarded to you as Attachment #37. 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 Field Manager was unaware that the screen was enclosed within the door so that screen was never inspected during the weekly house inspections. The Field Manager has now been made aware to look for those types of screens in the storm doors as they are becoming very common. 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. 09/28/2018 Implemented
6400.73(a)The last step off the porch was not equipped with a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. It is important to ensure the health and safety of all the individual¿s that we support. QLS failed to acknowledge the need for handrails in this specific circumstance. We do extensive home inspections prior to even opening a residence and this lack of handrailing was an oversight as the stairs themselves had handrailing, but due to the extensive length of the cement pads no one ever considered these as steps. Handrails were extended on September 28, 2018 to cover the expanded step area that contains the cement pads. Attachment #36 is photographs showing the completed work. The initial LIS will be conducted by the compliance director and reviewed by the Operations Manager before being submitted to ODP. This check will now be conducted with the knowledge of any step needing a handrail. 09/28/2018 Implemented
6400.112(c)The home is not checking all smoke detectors every month. Staff at the home indicated they push one alarm and listen for the rest to sound. There are multiple smoke detectors by the individual's bedrooms that aren't on the interconnected alarm system and not checked for operability every month. The basement which has a smoke detector is locked and the agency maintenance man has the key. He does not check the smoke detectors for operability every month at the same time the fire drills occur.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. This is important because QLS wants to ensure the safety and wellbeing of the individuals in the case of an emergency. QLS direct care staff was not checking all smoke detectors for operability. Staff failed to adhere to properly answer the questions on the written fire drill form. As of October 25, 2018, at a company meeting, all staff have been made aware of the need to check all fire alarms. We reviewed our form regarding compliance in this area and it was determined that the form lacked detail when it came to the area of distinguishing interconnect alarms vs. non-interconnect alarms. Our Fire Drill Form was updated to contain 2 questions. It now specifies to check all alarms whether they are interconnected or non-interconnected. These fire drill forms are generated by the Program Specialist and will be utilized companywide moving forward as fire drills are being conducted. The Fire Drill Form is reviewed by the operations department upon its completion by the residential staff. 10/25/2018 Implemented
SIN-00270554 Unannounced Monitoring 07/24/2025 Compliant - Finalized
SIN-00200643 Unannounced Monitoring 02/15/2022 Compliant - Finalized
SIN-00195765 Renewal 11/30/2021 Compliant - Finalized