What to Expect During a LARA Audit — and How to Prepare

Your Guide to Navigating Michigan’s Adult Care Compliance Inspections

If you operate an Adult Foster Care (AFC) home or Home for the Aged (HFA) in Michigan, chances are you’ll undergo a LARA (Licensing and Regulatory Affairs) audit or inspection — sometimes with little or no warning.

Whether you're a new licensee or a seasoned provider, understanding what LARA auditors look for — and preparing properly — can mean the difference between a clean inspection and a corrective action plan (or worse).

🧾 What Is a LARA Audit?

A LARA audit is a state-mandated compliance inspection of your licensed care facility. These reviews may be:

• Routine (annual/biannual)

• Triggered (complaints or serious incidents)

• Follow-up (corrective actions or re-licensing)

Inspectors evaluate whether your facility meets the Michigan Administrative Code for AFCs or HFAs, covering areas such as:

• Resident rights and care

• Staffing and training

• Environment and safety

• Incident reporting and documentation

• Medication management

• Policy and procedural compliance

🔍 What LARA Inspectors Look For

Here are the most common areas inspectors focus on:

1. Resident Records

Expect LARA to review files for:

• Current Health Care Appraisals

• Signed Resident Care Agreements

• Assessment plans and updated service needs

• Emergency contacts and consent forms

• Accurate incident/accident reports (e.g. BCAL-4607)

Tip: Files should be organized, dated, signed, and easy to access.

2. Staff Files

Inspectors will look for:

• Background checks (including fingerprinting and BCAL-1326A forms)

• Valid CPR, First Aid, and training certifications

• Staff qualifications and position descriptions

• Training logs for topics like Resident Rights, Fire Safety, Dementia Care, and Bloodborne Pathogens

Tip: Make sure all documentation is up to date — no expired certs!

3. Medication and Health Care Practices

LARA will verify:

• Medication logs and med pass documentation

• Proper storage (locked, labeled, separated by resident)

• MARs (Medication Administration Records) with signatures and times

• PRN and narcotic tracking

• Staff administering meds are properly trained and delegated (if applicable)

4. Physical Environment

They’ll inspect:

• Water temperature, lighting, and ventilation

• Cleanliness and organization of living areas

• Working smoke detectors and fire extinguishers

• Posted evacuation plans and emergency procedures

• Evidence of regular fire drills and inspections

5. Policies and Procedures

Auditors expect:

• Clear house rules and staff/resident policies

• Emergency and disaster preparedness plans

• Resident complaint procedures

• Documentation of policy review and staff acknowledgement

⚠️ Common LARA Citations to Avoid

• Missing health appraisals

• Staff without current CPR/First Aid

• Unlocked or mislabeled medications

• Incomplete incident reports

• Unsafe resident environments (e.g. tripping hazards, blocked exits)

• Improperly documented or expired training

📂 How to Prepare for a LARA Audit

✅ 1. Conduct Internal File Audits

Set a recurring calendar reminder to review:

• 2–3 resident files

• 2 staff files

• Training logs

• Medication records

• Facility safety walkthroughs

✅ 2. Keep a Licensing Binder

Include:

• Most recent license & inspections

• Staff list with hire dates and roles

• Training completion logs

• Emergency procedures

• Policy acknowledgment forms

✅ 3. Train Staff to Stay Calm and Informed

LARA inspectors may ask your staff:

• "What do you do in a fire?"

• "Where are your emergency contacts kept?"

• "How do you handle a resident fall or complaint?"

Make sure they’re prepared to answer confidently and honestly.

📉 What Happens If You’re Found Out of Compliance?

You may receive:

• A Corrective Action Plan (CAP)

• A temporary hold on new admissions

• Fines or license suspension for major violations

• A re-inspection to verify compliance

🛡️ Roseberri Can Help You Stay Audit-Ready

At Roseberri, LLC, we help Michigan AFC and HFA providers:

• Conduct mock audits

• Organize compliant resident and staff files

• Develop policies and procedures

• Prepare for licensing renewals and surprise visits

• Train staff on licensing expectations

💼 Don’t wait for a citation to get compliant.📧 Contact us today at roseberrimanagement@gmail.com to schedule your LARA compliance check-up.