Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217957 Renewal 01/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace inspections and cleanings performed on 09/08/21 and 09/06/22 were not completed by a professional furnace cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Lifeway Services immediately will use a Professional Furnace Cleaning company to perform a cleaning & inspection of each furnace within the service locations, at least once a year. This cleaning & inspection will be recorded on the Heating, Ventilation, and Air Conditioning (HVAC) company¿s provided Furnace Cleaning & Maintenance Report, and will be filed and recorded by the agency¿s standards & compliance department. Immediate remediation includes an engagement agreement between Lifeway Services, LLC and a local furnace company (executed on 2/2/2023, which details that all site¿s cleanings & inspections will occur annually. These initial cleanings & inspections will be performed between the dates of 2/7/23 and 2/15/2023 02/03/2023 Implemented
SIN-00184816 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination, completed 6/5/20, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. All individuals annual physical forms will be reviewed for accuracy and completion by the Program Specialists and the agency¿s Standards & Compliance Dept. Forms will be returned promptly to the physician¿s office for correction in the event they are submitted incomplete. 03/29/2021 Implemented
6400.141(c)(15)Individual #1's physical examination, completed 6/5/20 did not include special instructions for the individual's diet. This section was left blank.The physical examination shall include:Special instructions for the individual's diet. All individuals annual physical forms will be reviewed for accuracy and completion by the Program Specialists and the agency¿s Standards & Compliance Dept. Forms will be returned promptly to the physician¿s office for correction in the event they are submitted incomplete. 03/29/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 11/30/20. The rights document did not include the following rights: 6400.32d, to be treated with dignity and respect; 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32i access/security to Individual possessions, 6400.32k to participation in the development and implementation of the individual plan; 6400.32p choose with whom to share a bedroom; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home; 6400.32t access to food anytime and 6400.32u make healthcare choices.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The agency¿s individual rights policy was updated to ensure the inclusion of all sections stated within 6400.32, and to reflect the addition of the following components; 6400.32 (a, d, e, f, g, i, k, p, r, s, t, u). The Program Specialists will immediately, upon admission to the home, and annually thereafter; meet with all individuals to inform and explain the updated individual rights and obtain signatures from all individuals/guardians. 03/29/2021 Implemented
SIN-00148713 Renewal 01/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The monthly fire drills held from 9/30/18 to 1/3/19 used the front door as the exit route. The home has two exit routes.Alternate exit routes shall be used during fire drills. The monthly fire drills held from 9/30/18 to 1/3/19 used the front door as the exit route. The home has two exit routes. Alternate exit routes shall be used during fire drills. What specific change will be made: A new electronic Fire Drill form has been developed to ensure all available exit routes will be used during the review period A Compliance Department and Compliance Team was developed to ensure oversight and compliance. Who will make the change: Compliance Department, Compliance Team (composed of Compliance Department representative, Program Specialist, Administration, and Training Department, Training Department, and DSP. When will the change be made: 2/1/19 How will the change be made: An electronic Fire Drill form has been developed that requires every question to be completed, including: The date the drill occurred The exact time the Fire Drill begins and ends: (a.m. and/or p.m. must be selected before this section can be completed) Exit route used Any problems encountered during drill Operational status of smoke detector In the event that the electronic record is not available, a paper Fire Drill record with a checklist prompting specifics listed above as well as other relevant factors will be used. All agency fire drill records will be reviewed by the Compliance Department weekly for: Timeliness and completion, including; Exact time Hour Minutes Seconds If drill occurred during a.m. or p.m. If an alternative route can be/was used The Compliance Team will meet monthly to review the Fire Drill forms/process and to ensure randomness occurs across all areas of the Fire Drill process including use of alternative exits. What system have you implemented to make sure that the same violation will not occur again: Electronic Fire Drill Form Compliance Department oversight Compliance Team reviews What training has been provided to your staff: The Compliance has reviewed regulation requirements, deficits, and developed corrective action plans The Training and Compliance Departments have been instructed of required processes. DCP training is being rolled out agency-wide beginning February 1, 2019 through March 1, 2019 and will be updated during annual training. 02/01/2019 Implemented
SIN-00169680 Renewal 01/22/2020 Compliant - Finalized