CRISIS RESIDENTIAL UNIT LICENSING REVIEW

FROM THE CEO:

“Strong care, stronger systems.”

To our community,

LifeWays is committed to transparency and continuous improvement across all services we provide to our community.

In February 2026, our Crisis Residential Unit (CRU) underwent a routine licensing review conducted by the Michigan Department of Licensing and Regulatory Affairs (LARA).

The review identified a small number of areas requiring corrective action, primarily related to documentation and procedural requirements. While these findings did not involve concerns related to clinical care, medication practices, or the safety of the facility, they represented areas where our processes needed to be strengthened to meet all regulatory expectations.

LifeWays took immediate action to address each finding. A corrective action plan was developed, submitted, and implemented within the required timeframe.

Following these actions, the CRU was approved for a two-year license renewal.

We are committed to learning from every review process and to sharing both our improvements and our progress openly.

Thank you for your continued trust.


Cassandra Watson

CEO, LifeWays

ASSESSMENT RESULTS

The licensing review identified three areas requiring corrective action:

  • Emergency preparedness drills were not conducted across all required shifts

  • Resident records were missing specific required information

  • Evacuation assessments were not completed within required timeframes

These findings were related to process consistency and documentation requirements and did not involve:

  • Clinical care delivery

  • Medication administration

  • Facility or environmental safety

  • Licensing reviews evaluate both the quality of care provided and the systems in place to support that care.

    In this case:

    • Core service delivery areas were operating as expected

    • The identified findings reflected gaps in documentation and timing requirements, rather than deficiencies in care

    These types of findings are addressed through corrective action to ensure processes are:

    • Consistent

    • Clearly documented

    • Fully aligned with state requirements

  • LifeWays developed and submitted a corrective action plan addressing each identified finding.

    All corrective actions were implemented within the required timeframe. Following review and acceptance of the plan:

    • The CRU was granted a full two-year license renewal

    • Updated processes were put in place to ensure continued compliance

    • Ongoing monitoring was established to maintain improvements

CORRECTIVE ACTION PLAN

LifeWays implemented the following actions to address the identified findings:

    • Established a structured schedule to ensure fire drills are conducted across all required shifts

    • Implemented tracking processes to ensure drills are completed and documented consistently

    • Developed and implemented a standardized intake and documentation form

    • Ensured all required demographic and record elements are consistently captured

    • Implemented a process to ensure evacuation assessments are completed within required timeframes

    • Established routine scheduling and tracking to maintain compliance

Timeline

Inspection Date: February 5, 2026

Corrective Action Plan Submitted: February 13, 2026

Corrective Actions Implemented: February 2026

License Renewal Issued: February 2026

Our Commitment

LifeWays is committed to maintaining strong, compliant systems that support high-quality care. These updates strengthen our internal processes and ensure continued alignment with state standards.

We will continue to monitor performance, reinforce expectations, and make improvements where needed.

LifeWays has been awarded the highest level of accreditation by CARF International.

LifeWays is also held to the highest level of care by our overseeing organization,
Mid-State Health Network (MSHN)