Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260890 Renewal 03/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)For Individual #1, on 4/13/24, the financial ledger for the individual showed that the balance was $137.67 and on 4/22/24, there was a purchase made in the amount of $26.48; the balance that was recorded was $111.15 but it should have been $111.19 which caused the balance to be incorrect moving forward.(2) Disbursements made to or for the individual. All individual funds have been reviewed, and Individual #1's money has been deposited into their account. Program Managers will double-check all financial ledger entries before finalizing balances to ensure accuracy. Completed on 3/12/2025. 03/12/2025 Implemented
6400.68(b)At the time of the inspection on 3/12/25, the water temperature in the downstairs half bathroom was 122 degrees, in the upstairs full bathroom it was 122.5 degrees and in the downstairs full bathroom it was 124.8 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water heater was adjusted on 3/18/2025 to ensure hot water temperatures remain within the range of 108°F to 120°F, in compliance with safety regulations. Temperatures were rechecked after the adjustment to confirm they were within the required range. 03/18/2025 Implemented
6400.111(f)The fire extinguishers were inspected on 1/4/24 and not again until 1/9/25, which is outside of the annual timeframe. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The next annual inspection has been scheduled to ensure continued adherence to fire safety regulations. The Program Director has been scheduled the annual inspection for December 2025. See attached for appointment confirmation. 03/18/2025 Implemented
6400.181(a)The annual assessment for Individual #1 from 2/7/25 was not fully completed due to missing several components, such as if the assessment was based on assessment instruments, interviews, progress notes, and observations; documentation of the individual's disability, including functional and medical limitations; the individual's lifetime medical history; and psychological evaluations. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual #1 and all individuals' assessments were corrected on 3/18/2025 for accuracy and to include all regulatory information. All Program Managers have been retrained on individuals' annual assessments and the new form created for GHHS. Pleased see attached for the individual#1 corrected assessment. 03/18/2025 Implemented
6400.24For staff member #4, there was a Prohibitive offense on their background check and there is not documentation that a review of their offense was completed with the staff member.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Criminal History review was completed for said staff on 3/24/25. 03/24/2025 Implemented
6400.34(a)The individual rights reviewed with Individual #1 on 1/18/25 did not review rights 31a through 31g.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.On 3/13/2025 individual rights of the individual form was updated for accuracy and to include all regulatory information needed. All Program Managers have been retrained and have verified all individual rights documents to be accurate and up to date. All program managers understand the process for reporting violation of rights to for all individuals served. Please see the attached for the revised document. 03/18/2025 Implemented
SIN-00241032 Renewal 03/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)At the time of the inspection, the concrete basement stairs leading to the backyard did not have a railing. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A handrail has been installed according to requirements. Picture has been provided of the installed handrail. 04/05/2024 Implemented
SIN-00221901 Renewal 04/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)(Repeated Violation - 4/5/22) The self-assessment completed 9/20/22 did not assess compliance with the following regulations: 6400.107, 6400.142b.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.Self-assessment that was completed on 8/30/22 did not include a summary the corrections for identified violations and was missing some sections. Another self-assessment was completed on 1/20/23, however, this was outside of 3 to 6 months prior to 12.28.22, when the previous certificate of compliance expired, and therefore not compliant. The assigned staff person who completed the 8/30/22 self-assessment is no longer with GHHS. An assessment has been scheduled for 7/15/23 (expiration of cert. is 12/28/23) and is saved on the shared outlook calendar, with invites to the program management. Additionally, training has been done based on this most recent licensing findings. Attached file: Self-assessment signed training policy on scheduling self-assessments. 05/17/2023 Implemented
6400.15(c)The self-assessment completed on 9/20/22 did not include a plan of correction for 6400.32b and 6400.82f.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Self-assessment that was completed on 8/30/22 did not include a summary the corrections for identified violations and was missing some sections. Another self-assessment was completed on 1/20/23, however, this was outside of 3 to 6 months prior to 12.28.22, when the previous certificate of compliance expired, and therefore not compliant. The assigned staff person who completed the 8/30/22 self-assessment is no longer with GHHS. An assessment has been scheduled for 7/15/23 (expiration of cert. is 12/28/23) and is saved on the shared outlook calendar, with invites to the program management. Additionally, training has been done based on this most recent licensing findings. Attached file: Self-assessment signed training policy on scheduling self-assessments. 05/17/2023 Implemented
6400.106(Repeated Violation - 4/5/22) As of the 4/5/23 inspection, the most recent furnace inspection and cleaning was conducted on 11/15/21.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. Most recent inspection was 1/27/23, however, this was outside the 12 months since the previous furnace inspection. Staff that were responsible to schedule and ensure completion of furnace inspection during that time period are no longer with the company. New agency management team was trained on this regulatory item to ensure annual inspection. The Program Manager has scheduled annual furnace inspection for the company owned houses, and request has been made to property manager of the rented homes, and it also saved as an appointment on the shared Outlook calendar. Inspection for 2023 has been scheduled with the furnace company and will take place on 9/5/23 and 9/6/23. Evidence is attached file: General fire Safety "Furnace signed training schedule policy." 05/17/2023 Implemented
6400.214(b)The most recent assessment in the home for Individual #1 was dated 2/15/21. The most recent assessment in the home for Individual #2 was dated 6/28/21. There was no ISP available in the home for Individual #1. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. A new assessment based on an entirely new format has been completed and sent to the team. The newly assigned Program Managers (previous PM is no longer with the company) has been trained and ensured the assessment is reviewed by staff and available on site. 05/17/2023 Implemented
SIN-00164783 Renewal 01/22/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Notification was not sent to the fire department until 06/30/19, the provider took possession of the home 05/15/19.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The notification to the fire department was sent on 06/30/19 the day that the individual supported moved into the location. Greater Hearts did not know that the notification was supposed to be sent on the day the agency took possession of the apartment. To prevent this violation in future, the agency will make it a point to notify the fire department when it takes ownership of an apartment or begins construction of a new home. Notifications will be sent immediately for all homes that are currently under construction or for apartments that have been leased pending move-in of clients. For all homes acquired on or after 2.5.2020, the notification to the fire department will be sent on the day that Greater Hearts takes possession of the home or begins construction. The Vice President in-charge of Operations who is responsible for acquisition of new homes will be responsible for sending the initial notification to the fire department. The CEO will monitor to ensure that the notification is sent accordingly. Thereafter, if there is any change in the circumstances described in the initial notification (such as changes in the mobility needs of clients or approved capacity), the program specialist for the home will send another notification to the fire department. The Program Specialist and Residential Supervisors will review the records of all individuals served annually to ensure that the notification to the fire department is current and contains all the necessary information. 02/03/2020 Implemented
6400.141(c)(7)Individual #1 had her gynecological exam completed 07/02/18 and not again until 07/23/19.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Residential Supervisor responsible for this individual has been retrained on this regulation on 1/31/2020 (see attached). Effective February 1, 2020, Residential Supervisors will track the annual physical examination (including gynecological exams) for all the individuals living in homes under their supervision. A review of current annual appointments was completed on 1/31/2020 to identify most recent dates. The most current appointments dates have been added to a tracking tool (see attachment). The Residential Supervisors will review the tracker at least twice monthly to determine which individuals are coming due for an annual health examination. The Residential Supervisor will contact the respective health care providers to schedule follow up annual appointment minimally 30 days prior to the due date. The Residential Supervisors will review annual appointment forms once completed and update the tracking tool accordingly. The program specialist will monitor to ensure that annual physical examinations are completed on time to ensure compliance with this regulation. 01/31/2020 Implemented
6400.32(b)Individual #1's DOA (Date of Admission) is 05/01/18, individual #1 did not have rights reviewed (per signature page) until 10/27/18).An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion.The program specialist responsible for this individual has been retrained on this regulation on 1/31/2020.Individual #1s rights though initially reviewed late on 10/27/18 has since then been reviewed on time annually. Additional an audit conducted on 1/31/2020 of the records of the last individual admitted to Greater Hearts by this program specialist revealed that he reviewed the civil and legal rights with the individual during the time of admission. Effective 1.31.2020, Program specialists will make it top priority to review the civil and legal rights afforded to individuals by law with the individuals and/or their legal guardian on the day of admission. Documentation showing that the review has been conducted will be kept as part of an individual¿s records. Residential supervisors who are usually present at the home on the day of admission will recheck the documentation to verify and confirm it completion. Additionally, the Quality Manager or designated personnel will audit the records of at least 50% of all newly admitted individuals annually to monitor compliance with this regulation. 01/31/2020 Implemented
SIN-00181671 Renewal 01/20/2021 Compliant - Finalized
SIN-00155786 Technical Assistance 05/20/2019 Compliant - Finalized