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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 5/21/25 at 10:31 AM, the door between the basement and the garage had a turn lock mechanism on the basement side of the door posing an obstructed egress form the garage when engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The program director, supervisor/program manager, and staff members are responsible for ensuring that all exits from the home are accessible and unobstructed. Team leaders and staff are accountable for submitting maintenance requests when assistance is needed to ensure that all doors function correctly and that stairways, hallways, doorways, and exits remain clear of obstructions. On May 21, 2025, the Greater Hearts maintenance contractor was notified by phone about the locked door between the basement and the garage. The locked doorknob was replaced on May 22, 2025, with a non-lock knob. Please refer to Attachment 1 (pictures of the fixed door) at Roberts Rd. (Note, I contacted the contractor when the knob was fixed, he confirmed it was the next day that is May 22nd, 2025, however, we received photo evidence from the program manager on June 3rd, 2025. Part of GHHS re-training and performance assessment she was demoted from Program Manager to Team Lead see attached signed job description). |
05/22/2025
| Implemented |
| 6400.110(e) | On 5/21/25 at 10:36 AM, the smoke detectors on each floor of the home were not interconnected. The home has three stories. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Greater Hearts Human Services prioritizes adhering to departmental regulations and maintaining compliance at all times to ensure the health and safety of our clients. The violation occurred because both the Program Director and the former CEO, who were responsible for overseeing the home when it opened, failed to check the smoke detectors to ensure they were interconnected. This issue went unnoticed during the initial inspection of the house, which took place before the license was issued in June 2024. Although a set of smoke detectors was ordered and maintenance was notified about the issue on May 22, 2025, the program manager mistakenly ordered the wrong detectors, resulting in a delay in implementation. Eventually, our maintenance contractor installed and tested the smoke detectors to ensure they were functioning correctly. The smoke detectors were repaired on June 14, 2025 (see Attachment 2). |
06/14/2025
| Implemented |
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