Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241033 Renewal 03/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)(Repeat from 4/3/23) Individual #1 had a gift card at the home at the time of the inspection. There was no log for the gift card keeping track of the balance.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The home was documenting the individual cash and maintaining cash on hand counts. They now also have a count and expense record to document and track the gift card balance. 04/02/2024 Implemented
6400.64(a)At the time of the inspection, the bathroom walls had dried yellow matter and hair on each of the walls. The back of the toilet had a dried yellow substance. The floorboards had a thick layer of dust.Clean and sanitary conditions shall be maintained in the home. Following the inspection the bathroom was cleaned and pictures were provided to the team. 04/04/2024 Implemented
6400.72(b)At the time of the inspection there was a hole the size of a quarter in the screen located in the staff office. Screens, windows and doors shall be in good repair. Following the inspection a maintainence request was put in with the propety management for the screen to be repaired (this is a rented property). Repaired on the following day 3/28/24. 04/04/2024 Implemented
6400.81(k)(6)At the time of the inspection, there was no mirror available in Individual #2's room.In bedrooms, each individual shall have the following: A mirror. Following the inspection individual #2's Supports Coordinator was contacted to update the ISP to reflect that the individual does not have nor want a mirror in their bedroom. The annual ISP meeting is being held on 4/11/24 and the ISP will be updated at that time. 04/11/2024 Implemented
6400.141(c)(1)The most recent physical completed on 11/8/23 documented the doctor reviewed the attached lifetime medical history. There was no attached lifetime medical history. The LMH in the record was not current.The physical examination shall include: A review of previous medical history. Following the inspection the Lifetime Medical history was updated and attatched to the physical and sent to the PCP for review. (physical already being sent to PCP for violation 141-c-11) 04/03/2024 Implemented
6400.141(c)(11)The most recent physical completed on 11/8/23 left the health maintenance needs, medication regiment, and bloodwork sections blank.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. Physical form was sent to PCP to be filled out in its entirety. 04/11/2024 Implemented
6400.141(c)(13)Individual #1's most recent physical completed on 11/8/23 indicates they are allergic to Haloperidol, Chlorpromazine, Sulfa Drugs, and Risperidone. The MAR lists the allergies as Haloperidol, Thorazine, and Sulfa Drugs.The physical examination shall include: Allergies or contraindicated medications.PDC was emailed on 4/2/24 to add all Allergies and contraindicated medications to the future MAR. MAR corrected on site following the inspection 3/27/24. 04/11/2024 Implemented
6400.141(c)(15)The most recent physical completed on 11/8/23 left the special diet instructions field blank.The physical examination shall include:Special instructions for the individual's diet. Physical form was sent to PCP to be filled out in its entirety 04/11/2024 Implemented
6400.142(g)Individual #1's dental hygiene plan was last written 1/9/23.A dental hygiene plan shall be rewritten at least annually. Dental Hygiene plan updated on 4/2/24. 04/02/2024 Implemented
6400.143(a)Individual #1 attended a dental cleaning appointment on 12/8/22. They have refused to attend a dental appointment since that day. They had four refusals from May 2023 to September 2023. There was no documentation that Individual #1 was educated on the importance of following doctor's recommendations. Individual #1 has also refused vision and hearing screenings with no follow-up education.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Team Lead and DSP's have completed the documentation for refusals for Individual #1. 04/18/2024 Implemented
6400.151(b)The physician did not date the physical completed for Staff #2. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Physical is dated for 3/11/24. On the physical exam the TB skin test is not signed for as it is a separate form which is also dated for 3/11/24. The date of initial injection was 3/8/24. The date for staff #2 to return to read TB skin test is listed as 3/10 or 3/11. The date of the actual TB reading was 3/11/24. Physician signed and dated physical on all lines on 4/6/24. 04/19/2024 Implemented
6400.181(a)(Repeat from 4/3/23) Individual #1's assessment completed on 1/1/24 was not fully complete. It was missing documentation in the following categories: Likes, Disability/Functional/Medical Limitations, Lifetime Medical History, Psychological, Progress in Health, and Progress in Community Integration. The Recreation section simply had the word "goal". 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. New assessment has been created and corrected for accuracy and to include all regulatory information. 04/18/2024 Implemented
6400.46(b)Staff #3 completed fire safety training on 10/14/22 and not again until 11/15/23, outside of the annual timeframe.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Compliance Manger has been trained and will be conducting fire safety training on company wide universal training dates. These are scheduled for June 3rd 2024 and January 3rd 2025 04/18/2024 Implemented
6400.166(a)(2)Individual #1 was administered ear drops on 11/29/23. The prescriber for this medication was not documented on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Following the inspection the prescriber of this medication was listed on the MAR. 04/11/2024 Implemented
6400.169(a)Staff #3's original medication administration training certification was 8/10/21. Staff #3 did not complete additional medication administration training until 9/26/23.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Staff #3 remediated medication administration course in its entirety. 04/19/2024 Implemented
SIN-00221902 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 on 9/2/22 did not assess compliance with the following regulations: 6400.181e9.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 9/2/22 did not include a plan of correction for 6400.181a.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. Another self-assessment was completed on 1/20/23, however, this was outside 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 based on the recent licensing inspection has been completed (for the house that was full review) and used as part of the training process, to include corrective action. 05/08/2023 Implemented
SIN-00202905 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. 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
6400.112(h)The 4/1/22 fire drill record lists "out front sidewalk" as the designated meeting place. The 3/15/22 fire drill record lists "out front of house" as the meeting place. The 2/3/22, fire drill record lists "sidewalk behind the house" as the meeting place. The 1/19/22 fire drill record has "front sidewalk" as the meeting place.The 12/13/21 and 11/16/21 fire drill records list the designated meeting place as "parking lot (house lot)". Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Residential Supervisor contacted the fire chief to set up a time when the chief and come to the homes to establish a safe meeting place. Fire chief came out on 4/7/22 and established safe meeting places for each home. Staff were immediately emailed informing them of the new meeting place. All staff and individuals will be trained on the new meeting place by 5/31/22. 04/27/2022 Implemented
SIN-00181672 Renewal 01/20/2021 Compliant - Finalized