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 openly shared the results of our recent Recipient Rights System Assessment conducted by the Michigan Department of Health and Human Services.

In early 2026, LifeWays received a status of Less Than Substantial Compliance on this assessment. We took this outcome seriously and we thought it was important to provide clear context around what this meant and how we would respond. We created the below webpage to share the findings and plans moving forward.

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 actively worked alongside our Quality Management team to develop a comprehensive corrective action plan that directly addressed each identified deficiency. This plan was submitted on March 11, 2026 and also had full resolution of the noted issues by that same month. We then received acceptance of our corrective action plan by MDHHS by July 2026.

We believe transparency is paramount in all that we do. That is why we publicly shared this letter, our assessment findings, and our corrective action results—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

Table showing site compliance scores in various sections like Responsibilities, Rights Office Operations, Education and Training, Policies, Recipient Rights Advisory Committee, Complaint Resolution, Appeals, Data Reports, and Site Visitation. Columns display total points, possible points, weight, and weighted scores, with a site score of 317 and a maximum score of 364.

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

- 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

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.