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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | On 5/21/25, between 12:16 PM and 12:20 PM, the following windows did not have screens: both windows in Individual #1's bedroom, both windows in the vacant bedroom, the window in the bathroom along the hallway on the first floor, and the window in the kitchen facing the back of the home. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Open windows must be equipped with screens to prevent bugs and other insects from entering the home, ensuring the safety and well-being of our clients. This violation occurred because neither the program director nor the former CEO, who had inspected, licensed, and prepared the house for the residents, was aware of the requirement for window screens. The need for screens was not noted during the initial inspection, which was part of the licensing process for the home and only came to light during our annual inspection. On the day of the inspection, we immediately contacted the GHHS maintenance contractor and scheduled a time for them to measure the windows. On June 15, 2025, the contractor visited the home in Havana to take the necessary measurements for building the screens. The manufacturing and installation of the screens are expected to take some time, with a projected completion date of June 23, 2025. |
06/23/2025
| Implemented |
| 6400.101 | On 5/21/25 at 12:25pm, the door betwwen 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 Havana Drive. |
05/22/2025
| Implemented |
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