Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221905 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 8/16/22 did not assess compliance with the following regulations: 6400.62a, 6400.142e, 6400.167a1, and 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 of 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 8/16/22 did not include a plan of correction for 6400.181f.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. Attached file: Self-assessment signed training policy on scheduling self-assessments. 05/17/2023 Implemented
6400.66At the time of the 4/5/23 inspection, there was no source of light in the room used as an office on the second floor of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 4/5/23, same day as inspection, a new lamp was installed with source of light. Evidence in form of a picture was provided to licensing inspector on the day of citation (attachment 1 772 Scarsdale lamp Attachment: Physical Site Weekly Checklist Training. 05/17/2023 Implemented
SIN-00202908 Renewal 04/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)No self-assessment was 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. 05/01/2022 Implemented
6400.22(c)Individual #1 purchased groceries throughout the year with their own money despite having a Snap Benefit card available to use.Individual funds and property shall be used for the individual's benefit. Individual #1 has started using their SNAP benefits when they go out and when their mother sees the Individual once a month the Individual's mother will take the card and the individual will use it for groceries of their choice Starting from 1/1/21 of last year until the date of inspection Greater Hearts refunded the individual money spent. The reimbursement amount is 1,675.63. This will be added to Individual #1's current cash on hand by 5/1/22. 04/27/2022 Implemented
6400.22(d)(1)Individual #1's balance should have been $199.24 in February 2021. It was recorded incorrectly as $199.42. The balance was never reconciled which in turn made it incorrect from that point on. In January 2022, the ending balance was $54.08. The starting balance in February 2022 was $54.04.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. Program Manager reviewed the records and refunded the individual 0.04 cents. 04/07/2022 Implemented
6400.22(e)(3)Individual #1's Receipt #13 in May 2021 is completely blank, making it impossible to verify the amount of the receipt. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Program Manager refunded the individual $13 which was what was recorded on the cash on hand log as the amount on the receipt. The receipt was destroyed probably over time by the glue on the tape that was used to keep receipts in place. Program managers talked to the staff in house meeting about properly documenting the cash on hand. Staff were advised to only tape the edges of the receipts putting small pieces of tape on all four corners. Greater Hearts will continue to use the same process for storing receipts; only assuring the receipts are taped correctly. Greater Hearts will retrain all staff on this by 5/1/22. Greater Hearts will also assure when audit of finances is occurring, staff review the receipts to ensure they are legible. 04/14/2022 Implemented
6400.82(f)At the time of the inspection on 4/6/22, there was no hand soap available in the upstairs bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Program Manager went to the house on 4/7/22 to add the soap in the upstairs bathroom. 04/07/2022 Implemented
6400.110(c)At the time of the inspection on 4/6/22, there was no fire extinguisher in the kitchen. The nearest fire extinguisher was located in the dining room.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. COO called Greater Hearts maintenance and notified them that the fire extinguisher needed to be moved from the dining area to the kitchen. Maintenance stopped by the house to move extinguisher into the kitchen. See attached 'kitchen fire extinguisher" picture. 04/12/2022 Implemented
6400.211(b)(3)There was no documentation in Individual #1's record as to who to contact for medical consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Greater Hearts updated the fact sheet to include the individuals Contact for medical consent. Also, COO has uploaded the updated fact sheet on Greater Hearts share point for everyone to have access to. 04/07/2022 Implemented
6400.32(o)Individual #1 has a Snap Benefit card, however staff chose not to use the card for food purchases at the store numerous times throughout the year when Individual #1 wanted to purchase additional groceries. Staff confirmed the card wasn't used for the convenience of not carrying two cards. Individual #1 then paid for the groceries with their petty cash instead of Snap benefit card.An individual has the right to manage and access the individual's finances.Greater Hearts trained staff on the need to use the individual SNAP benefits first before using the cash when the individual requests to go out shopping. Individual #1 will be reimbursed 1,675.63 by 5/1/22. 04/27/2022 Implemented
6400.213(1)(i)There was no documentation clearly identifying Individual #1's next of kin.Each individual's record must include the following information: Next of KinGreater Hearts updated the fact sheet to include the individuals next of kin. Also, the updated fact sheet was uploaded onto Greater Hearts share point for everyone to have access to. 04/07/2022 Implemented
6400.213(1)(i)There was no documentation in Individual #1's record as to what their religious affiliation was. The documentation indicated "unknown."Each individual's record must include the following information: Religious AffiliationGreater Hearts reached out to the individuals mother and got the family's/individuals religious affiliation. The individual record was updated with individual's religious affliction. Please see attached ' updated face sheet' 04/07/2022 Implemented