Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221898 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 dated 7/12/22 was not complete. Most regulations were not assessed.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
6400.141(c)(14)The medical information pertinent to diagnosis and treatment in the case of an emergency section of Individual #1's 3/6/23 annual physical examination was not documented by the physician.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The violation was due to an oversight and was corrected as soon as it was brought to our attention. The physician at MedExpress included the missing information pertinent to diagnosis and treatment and the evidence was provided on 4/7/23. Attached files: Individual Health, and 338 Honey Physical, Fact sheet with weight added, Individual Records. 05/17/2023 Implemented
6400.141(c)(15)Individual #1's dietary needs were not documented by the physician at their 3/6/23 annual physical examination.The physical examination shall include:Special instructions for the individual's diet. Violation was corrected on 4/5/23, and evidence was presented, and is reattached. New Program Manager is trained on the admission process and ensuring that the individuals served shall have a physical examination that includes Special instructions for the individuals diet. Attached files: Individual Health, and 338 Honey Physical, Fact sheet with weight added, Individual Records. 05/17/2023 Implemented
6400.34(a)(Repeated Violation - 4/5/22) The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 04/04/2023 annual inspection, Individual #1 was never informed of the individual rights as described in 6400.32, specifically all the rights listed in regulation 6400.32a.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.The violation was corrected and updated form with all listed individual rights, as well as the process for filing a compliant, was reviewed and discussed with the individual, and also signed. Individuals and staff have reviewed the updated form with all rights listed. The Program Manager is responsible to review the individual rights and process for reporting a violation with the individual upon admission and annually thereafter (at a minimum) Target Date 5/17/23 05/17/2023 Implemented
6400.213(1)(i)Individual #1's weight is not documented in their record.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number, and weight.This violation on individual records was corrected, and evidence attached. Newly assigned Program Manager and staff are trained on Individual Records to include: (i) The name, sex, admission date, birthdate and Social Security number, and weight. Attached file: Individual records training and policy. 05/17/2023 Implemented
SIN-00202901 Renewal 04/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no self-assessment completed for this home.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.The self-assessments for 2021 were incomplete because all administrative personnel were working providing direct support in the homes. Greater Hearts will be doing self-assessments for all homes by 5/1/22.. The self-assessments will include vacant homes as well. 04/27/2022 Implemented
6400.77(b)At the time of the inspection on 4/6/22, the first aid kit did not contain antiseptic. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. COO ordered antiseptic wipes in bulk for the first aid kit at the home so that they are readily available to all the homes at all times. 04/19/2022 Implemented
6400.110(e)At the time of the inspection, when the smoke detector on the main level of the home went off, none of the other smoke detectors in the home went off.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. On 4.19.22 the COO, sent an email to the apartment manager in charge. The email stated that the smoke detectors did not go off simultaneously like they usually do and requested that someone come to the house and fix the issue. COO also requested for documentation after the issue had been addressed which was received on 4.20.22. It is attached as ' 338 smoke detectors". 04/25/2022 Implemented
SIN-00148704 Renewal 01/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(17)Individual #1's April 10, 2018 Dietary Restrictions Plan, completed by Staff Person #X, the program specialist, reads that Individual #1 is allergic to soy beans, green beans, oregano, cow milk, cottage cheese, fructose, solanine, pecans, walnuts, pineapple, salicylic acid, and tramine. The plan goes on to read that Individual #1 has a peanut allergy in the "red zone," which means that immediate medical attention may be required if peanuts are ingested. Individual #1's April 30, 2018 diabetic protocol reads, in part, "Blood sugar below 60 -- give 4 glucose tabs and repeat blood sugar in 15 minutes. If still less than 60 please repeat. If above 60 on recheck -- eat a small snack such as 3 peanut butter crackers." Although Individual #1 never had a blood sugar reading that necessitated providing crackers, peanut butter crackers were present in the home to be used if necessary, creating a risk of serious allergic reaction. Additionally, there are substantial discrepancies in Individual #1's record relating to her allergies. In addition to the April 10, 2018 Dietary Restrictions Plan, Individual #1's September 2, 2018 medical evaluation documentation lists "food dye" as Individual #1's only allergy, and Individual #1's October 26, 2018 Individual Support Plan lists food dye and peanuts" as the only allergies. The program specialist did not effectively coordinate Individual #1's services such that the individual is at risk of experiencing a serious allergic reaction to peanuts or other food items. The program specialist shall be responsible for the following: Coordinating the services provided to an individual. Allergy discrepancy ¿ food dye. It is important that no inconsistencies are present in the record to assure people are being supported with current and correct information. Individual #1¿s allergies listed in the ISP are not consistent with allergies listed on other documentation throughout the record. Peanut cracker: Program Specialist did not effectively coordinate individual #1 services with the appropriate medical providers to ensure that they have the necessary medical information to ensure the health and safety of the individual. A new diabetic protocol has been obtained from the endocrinologist as of 1/17/19. The discrepancy has since been corrected 1/17/19 and updated on all records and ISP was updated and sent to SC for revision 1/17/19. See attachment #9 of allergy list sent to SC and e-mails indicating update of ISP. Allergy list/results should be provided to all medical contacts so that they are aware of her food allergies including allergy to peanut. A complete list of food allergies as per the results should be made and sent to the support coordinator to update the ISP ¿ has been done as of 1/17/19. A policy update would be done to require supervisors and PS to read entire ISP within 7 ¿ 14 days once an update is received and send out correspondence to SC to rectify any discrepancies. A print out of any correspondence should be kept on file. Compliance Specialist (Provider has hired a compliance Specialist) will review client documents at least one full inspection every year using the LII and ensure that corrective actions are taken and documented when necessary. The completed LII should be kept on file. The violation occurred because the Program Specialist failed to effectively perform his job responsibilities as described in the in his job description upon hired. Program Director, QM and owner are meeting with PS on 2/13/19 to discuss his job performance. In the future, discrepancies will be resolved prior to admission with the referral agency/and or parents and appropriate documentation obtained. The Program Specialist, supervisor, CEO and Residential Director will be trained on this regulation and their responsibility on this regulation dated 2/28/2019. The Program Specialist is responsible to assure compliance to this regulation. The Program Specialist, CEO, supervisor and Residential Director will be trained on 2/28/19 on this regulation and their responsibility to meet this regulation in the future. The Residential Director, CEO; Program Specialist and supervisors will review a minimum of 12% of ISP reviews during this licensing year. And 10% of all documents will be reviewed every quarter. 02/28/2019 Implemented
6400.141(c)(11)Emergency medical plan- diabetic protocol from the endocrinologist on 4/30/18 for Individual #1 states : Blood sugar below 60- give 4 glucose tabs and repeat blood sugar in 15 min. If still less than 60 please repeat. If above 60 on recheck- eat a small snack such as 3 peanut butter crackers. If Blood sugar is above 300 drink 12 ounces of water over 60 min. Then retest BS in 60 min. If BS is above 400 call the doctor office. This info is not on the 9/6/18 physical in the emergency medical info. There is only a slash mark in this section.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The regulation is important because staff and medical personnel need to know what to do for individuals in an emergency to support them in a safe, healthy manner. This violation occurred because the supervisor and Program Specialist overlooked the blank area on the form and failed to follow up with the PCP to complete the necessary information. Individual has a diabetic protocol that was not attached to her physical examination dated 9/6/18 or referenced on the section of the physical regarding what to do in an emergency. The supervisor for the site has a scheduled appointment 2/14/2019 with individual #1 PCP to include this information to include the individual health maintenance needs. See attachment #8 copy of appointment. Supervisors, PS and CEO/Program Director will audit 10% of all documents will be reviewed every quarter. Diabetic protocol should be made available to all her medical contacts especially her PCP and a formal medical emergency guideline requested from her PCP as a supplement to the physical examination. This should include a list of her food allergies and the need to check her sugar level in a medical emergency. To prevent future occurrence, residential supervisor and Program Specialist shall review the physical examination form prior to the annual physical appointment in order to ensure that pertinent information is attached or provided to enable the PCP to conduct a comprehensive physical. The forms should be reviewed afterwards as well. Residential Supervisor and Program Specialist will be train on this regulation on 2/28/19. Supervisors, PS and CEO/Program Director will audit 10% of all documents will be reviewed every quarter. 02/28/2019 Implemented
6400.164(b)Medications for Individual #1, the ammonium Lactate 12% cream Lac-Hydrin 12% cream apply topically 2xs day 4:30-5am not signed as applied on 10/26/18. 8/21/18- Ibuprofen 200mg was administered by staff by no time is on the MAR when it was administered. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. It is very important that each staff initial immediately after each individual dose of medication to assure that medication was administered. This is especially concerning because the blank spot is for a tropical cream and therefore it cannot be readily determined that the staff personal failed to fill out the MAR or that the medication were not administered. In the event that it cannot be confirmed that an individual received their medication, a medication Error Omission report will be filed in EIM. Ibuprofen though it was administered staff did not write the time it was given. Upon inspection it appears both medication errors were done by a single staff. The staff responsible will be retrain (Feb 21-Feb 22 see attachment of trainers e-mail) on medication errors and documentation and responsibilities to document on MAR after each administration and to check all documentation at the beginning and end of their shift as well as document the time a PRN medication is given during his shift. The site supervisor is responsible to assure that the MAR documentation is completed timely and to follow up immediately when a discrepancy is discovered. Supervisor will submit MARS to the compliance specialist for review at the months end. Supervisors will report any discrepancies to the Program Specialist and appropriate corrective action will be implemented. The supervisor, Program Specialist and Program Director will be trained on (date) this regulation their responsibility in meeting the regulation. Supervisors, PS and CEO/Program Director will audit 10% of all documents will be reviewed every quarter. 02/21/2018 Implemented
6400.186(a)The ISP review for individual #1 dated 1/7/18 was completed and reviewed by the Individual late- the review period was 9/7/18-12/6/18. This review should have been completed by 12/21/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. 6400.186(a) The supervisor, Program Specialist are responsible for meeting this regulation. The Supervisor and Program Specialist will be train on 2/28/2109 on this regulation. Program Specialist will review monthly safety check list after its completed by the supervisor ¿ monthly. It is important that each person supported, and their team get timely updates regarding the progress and changes to supports. This assures all team members are providing supports with current information. The three-month review was not completed within 10 days following the completion of the quarter. This violation occurred because the Program Specialist had a family emergency (death of two family members days apart) and was unable to complete the quarterly in a timely manner. The Program Specialist is responsible to assure compliance to this regulation. The Program Specialist will be train on this regulation and his responsibility to meet this regulation on 2/28/2019. GHHS has acquired Office 365 which comes with MS Outlook. PS will use the Outlook Calendar to schedule the quarterly due dates for all clients under his/her supervision. The alert function of the MS outlook will be enabled to ensure that the PS receives e-mail alerts a week as well as a day prior to the quarterly due dates. Program Director will be copied on this alert and will follow up with PS to ensure that all required quarterlies are completed on time. It will be the responsibility of the Residential Director to assure that the ISP reviews and assessments are completed as per the regulations by a review of 10% documents every quarter. 02/28/2019 Implemented
SIN-00181668 Renewal 01/20/2021 Compliant - Finalized
SIN-00164778 Renewal 01/22/2020 Compliant - Finalized