RECIPIENT RIGHTS ASSESSMENT:
WHAT WE’RE IMPROVING
FROM THE CEO:
“Transparency is paramount in all that we do.”
To our community,
At LifeWays, transparency and accountability are foundational to the trust placed in us by the people we serve, our partners, and our community. In that spirit, we want to openly share the results of our recent Recipient Rights System Assessment conducted by the Michigan Department of Health and Human Services.
LifeWays received a status of Less Than Substantial Compliance on this assessment. We take this outcome seriously and we think it is important to provide clear context around what this means and how we are responding.
The findings from the assessment were primarily procedural in nature, focusing on policy and process updates as well as the structure of our appeals committee. Importantly, the assessment did not identify concerns related to the quality of care provided to individuals we serve. In fact, assessors specifically recognized and celebrated the significant improvements LifeWays has made in both our site visit process and the quality of our investigations and investigative reports—progress we are proud of and committed to sustaining.
Our Recipient Rights team is actively working alongside our Quality Management team to develop a comprehensive corrective action plan that directly addresses each identified deficiency. This plan will be submitted by March 11, 2026, and we anticipate full resolution of the noted issues by March 2026.
We believe transparency is paramount in all that we do. That is why we are publicly sharing both this letter and our assessment findings—to ensure our community understands where we are, what we are improving, and how seriously we take our responsibility to uphold recipient rights.
LifeWays remains deeply committed to continuous improvement, compliance, and—above all—respect, dignity, and advocacy for the individuals and families we serve. We appreciate the opportunity to learn, strengthen our systems, and demonstrate our commitment to doing better every day.
Thank you for your continued trust.
Cassandra Watson
CEO, LifeWays
ASSESSMENT RESULTS
-
LifeWays’ Recipient Rights System Assessment resulted in a score of 317 out of 364, which falls within the state’s designation of Less Than Substantial Compliance.
This designation reflects gaps in specific policies, procedures, and oversight structures, rather than concerns about the safety, dignity, or quality of services provided to individuals. The assessment did not identify systemic failures in investigations, site visits, or complaint handling—in fact, reviewers noted meaningful improvements in these areas.
The scoring system is weighted, meaning certain categories (such as policies and appeals) carry greater impact on the final score. In LifeWays’ case, lower scores in a small number of high-weight areas significantly affected the overall result.
While this outcome requires corrective action, it also provides a clear roadmap for improvement. We are addressing each identified issue directly and transparently.
-
LifeWays is actively working with its Recipient Rights and Quality Management teams to implement corrective actions for each identified deficiency.
A formal Corrective Action Plan will be submitted to the state by March 11, 2026
All identified issues are expected to be fully resolved by March 2026
Updates include policy revisions, procedural clarifications, and improvements to the appeals process
Progress will be monitored to ensure changes are sustained—not just implemented
We are sharing both the assessment results and our assessment results publicly because transparency and accountability are central to our mission. This process strengthens our system and helps ensure we continue to protect and advocate for the rights of those we serve.
CORRECTIVE ACTION PLAN
LifeWays has developed and implemented a comprehensive corrective action plan to address the findings identified in the Recipient Rights System Assessment. The actions below reflect both operational improvements and extensive policy updates to ensure full compliance with state requirements.
-
Reviewing and updating Recipient Rights policies to ensure full alignment with state requirements
Clarifying procedures to promote consistency across all programs
Implementing regular review cycles to maintain accuracy and compliance
-
Strengthening the structure and documentation of the appeals committee
Ensuring clear roles, timelines, and decision-making processes
Providing additional guidance and training to support consistent application
-
Improving documentation practices to ensure completeness and accuracy
Enhancing internal tracking and oversight of Recipient Rights processes
Conducting regular audits to ensure sustained compliance
-
Providing targeted training on updated policies and procedures
Reinforcing expectations related to Recipient Rights practices
Supporting staff with tools and resources to ensure consistency
-
Partnering with Quality Management to monitor progress
Establishing accountability measures and timelines for completion
Ensuring continuous review and improvement beyond initial corrective actions
Timeline
Corrective Action Plan Submitted: March 11, 2026
Target Completion: March 2026
Advisory Councils + Committees
LifeWays is committed to including the voices of those we serve. We achieve this, in part, with the use of advisory councils and committees.
Consumer Advisory Council
Recipient Rights Advisory Committee
Self-Determination Advisory Committee
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)