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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 5/21/25 at 11:36 AM, the hot water temperature measured 122.5F at the sink in the bathroom across from the staff office on the first floor of the home. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The regulation is necessary because it minimizes the risk of individuals suffering burns from contact with exposed heat sources. A violation occurred because the program director failed to conduct self-assessment checks before the inspection and did not verify that all water heaters in the home met the required regulations. Additionally, she did not follow up with staff when water temperature checks were delegated to them. To address this, the water temperature was adjusted according to regulations (by the maintenance contractor), and checks were performed on all faucets to ensure consistency (see Attachment 5). These tests were conducted at least three times to maintain a steady temperature. The water heater was adjusted to maintain a water temperature between 98.0°F or 97.9°F. |
05/22/2025
| Implemented |
| 6400.72(a) | On 5/21/25 at 11:34 AM, the window facing the right side of the home from Individual #1's bedroom, and the window facing the right side of the home from the staff office, did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | All open windows must have screens to prevent bugs and other insects from entering the home. A violation occurred because neither the program director nor the former CEO, who had inspected, licensed, and prepared the house for the individuals moving in, was aware that screen installation was necessary. This requirement was not noted during the initial inspection as part of the licensing process until our annual inspection on May 21, 2025. On the day of our inspection, we promptly contacted the GHHS maintenance contractor and scheduled a time for them to measure the windows. On June 3, 2025, the contractor visited the home in Nash to take the necessary measurements for building the window screens. The screens will take some time to design and install, with a projected completion date of June 23, 2025. The license supervisor will be notified via email of any changes or delay to the projected date. |
06/23/2025
| Implemented |
| 6400.101 | On 5/21/25 at 11:44AM, the door between the basement and the garage had a turn lock on the basement-side of the door, posing an obstruced egress from 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 (pictures of the fixed door) at Nash Ave. |
05/22/2025
| Implemented |
| 6400.162(c)(3) | Lorazepam, 1mg prescribed to Individual #1 was discontinued 5/10/2025. On 5/21/2025 at 11:20AM, the bubble pack for the discontinued medication remained in Individual #1's medication box. | Medication administration includes the following activities, based on the needs of the individual: Prepare the medication as ordered by the prescriber. | Staff must understand that when a medication is discontinued, it should be immediately removed and disposed of by GHHS regulations. It is crucial to keep our clients safe by eliminating any discontinued medications to prevent adverse effects or accidental administration. In this case, the staff member who discontinued the medication "forgot" to remove it from the medical box, which the inspector discovered during the licensing process on May 21st, 2025. Moreover, the program director or program specialist did not review the medication records and client files (medication log), nor did they check the medication box. |
05/21/2025
| Implemented |
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