Hearts with Hope Foundation-GRO

Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.

Resolution: Corrected: 2026-02-20

Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.

Resolution: Corrected: 2026-02-20

Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.

Resolution: Corrected: 2026-02-20

Caregivers did not follow children's service plan when children in care stayed in the operation van without staff knowing.

Resolution: Corrected: 2026-02-20

Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.

Resolution: Corrected: 2025-05-16

Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.

Resolution: Corrected: 2025-05-16

Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.

Resolution: Corrected: 2025-05-16

Upon review of personnel records, one file lacked reference checks required for employees hired after August 2023.

Resolution: Corrected: 2025-05-16

During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.

Resolution: Corrected: 2025-05-01

During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.

Resolution: Corrected: 2025-05-01

During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.

Resolution: Corrected: 2025-05-01

During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.

Resolution: Corrected: 2025-05-01

During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.

Resolution: Corrected: 2025-05-01

During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.

Resolution: Corrected: 2025-05-01

During the course of the investigation, it was found that there was no report to licensing within the 6-hour timeframe.

Resolution: Corrected: 2025-05-01

During the course of this investigation, it was found that there was no report to law enforcement within the six-hour timeframe.

Resolution: Corrected: 2025-05-01

Age, gender and date of admission of the child/children involved not found in document.

Resolution: Corrected: 2024-12-27

Age, gender and date of admission of the child/children involved not found in document.

Resolution: Corrected: 2024-12-27

Age, gender and date of admission of the child/children involved not found in document.

Resolution: Corrected: 2024-12-27

Age, gender and date of admission of the child/children involved not found in document.

Resolution: Corrected: 2024-12-27

There was a bag of chicken left to thaw in the kitchen sink.

Resolution: Corrected at inspection

There was a bag of chicken left to thaw in the kitchen sink.

Resolution: Corrected at inspection

There was a bag of chicken left to thaw in the kitchen sink.

Resolution: Corrected at inspection

There was a bag of chicken left to thaw in the kitchen sink.

Resolution: Corrected at inspection

One of the medication logs did not accurately reflect the pills counted.

Resolution: Corrected: 2024-03-11

While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.

Resolution: Corrected: 2024-03-11

While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.

Resolution: Corrected: 2024-03-11

One of the medication logs did not accurately reflect the pills counted.

Resolution: Corrected: 2024-03-11

While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.

Resolution: Corrected: 2024-03-11

One of the medication logs did not accurately reflect the pills counted.

Resolution: Corrected: 2024-03-11

One of the medication logs did not accurately reflect the pills counted.

Resolution: Corrected: 2024-03-11

While reviewing medication records, multiple medication logs for nasal spray were not administered daily as prescribed for 5 children out of 16.

Resolution: Corrected: 2024-03-11

Three out of the four child files reviewed did not have a hearing screening.

Resolution: Corrected: 2023-12-07

Three out of the four child files reviewed did not have a hearing screening.

Resolution: Corrected: 2023-12-07

Three out of the four child files reviewed did not have a hearing screening.

Resolution: Corrected: 2023-12-07

Three out of the four child files reviewed did not have a hearing screening.

Resolution: Corrected: 2023-12-07

It was determined that an unauthorized person consented to medication during a child in cares hospital stay.

Resolution: Corrected: 2023-11-15

It was determined that an unauthorized person consented to medication during a child in cares hospital stay.

Resolution: Corrected: 2023-11-15

It was determined that an unauthorized person consented to medication during a child in cares hospital stay.

Resolution: Corrected: 2023-11-15

It was determined that an unauthorized person consented to medication during a child in cares hospital stay.

Resolution: Corrected: 2023-11-15

During the investigation it was found that a child in care was left unsupervised.

Resolution: Corrected: 2023-10-13

During the investigation it was found that a child in care was left unsupervised.

Resolution: Corrected: 2023-10-13

During the investigation it was found that a child in care was left unsupervised.

Resolution: Corrected: 2023-10-13

During the investigation it was found that a child in care was left unsupervised.

Resolution: Corrected: 2023-10-13

A resident in care used a staff members cell phone to communicate with an individual.

Resolution: Corrected: 2023-12-15

A resident in care used a staff members cell phone to communicate with an individual.

Resolution: Corrected: 2023-12-15

A resident in care used a staff members cell phone to communicate with an individual.

Resolution: Corrected: 2023-12-15

A resident in care used a staff members cell phone to communicate with an individual.

Resolution: Corrected: 2023-12-15

A child in care was physically harmed while attempting to deescalate her peers from engaging in an altercation.

Resolution: Corrected: 2023-08-24

A child in care was physically harmed while attempting to deescalate her peers from engaging in an altercation.

Resolution: Corrected: 2023-08-24

A child in care was physically harmed while attempting to deescalate her peers from engaging in an altercation.

Resolution: Corrected: 2023-08-24

A child in care was physically harmed while attempting to deescalate her peers from engaging in an altercation.

Resolution: Corrected: 2023-08-24

6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.

Resolution: Corrected: 2023-07-06

The staffing plan provided does not include a plan for back up care providers for emergencies.

Resolution: Corrected: 2023-07-06

The Case Manager is currently still performing the job responsibilities of a PLSP such as admissions assessments.

Resolution: Corrected: 2023-07-06

6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.

Resolution: Corrected: 2023-07-06

The staffing plan provided does not include a plan for back up care providers for emergencies.

Resolution: Corrected: 2023-07-06

The Case Manager is currently still performing the job responsibilities of a PLSP such as admissions assessments.

Resolution: Corrected: 2023-07-06

6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.

Resolution: Corrected: 2023-07-06

The staffing plan provided does not include a plan for back up care providers for emergencies.

Resolution: Corrected: 2023-07-06

The Case Manager is currently still performing the job responsibilities of a PLSP such as admissions assessments.

Resolution: Corrected: 2023-07-06

The Case Manager is currently still performing the job responsibilities of a PLSP such as admissions assessments.

Resolution: Corrected: 2023-07-06

6 out of 9 child medications reviewed it was noted that the reason the medication was prescribed, prescribing physician and the side effects were not documented on the medication record.

Resolution: Corrected: 2023-07-06

The staffing plan provided does not include a plan for back up care providers for emergencies.

Resolution: Corrected: 2023-07-06

There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.

Resolution: Corrected: 2023-06-08

All staff files reviewed did not contain written knowledge and competency of the training material.

Resolution: Corrected: 2023-06-08

A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.

Resolution: Corrected: 2023-06-08

The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.

Resolution: Corrected: 2023-06-08

One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.

Resolution: Corrected: 2023-06-08

One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.

Resolution: Corrected: 2023-06-09

A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.

Resolution: Corrected: 2023-06-08

The Disaster and Emergency curriculum does not have the required components such as the location and use of the fire extinguishers and first aid equipment.

Resolution: Corrected: 2023-06-08

The training logs that were observed were not accurate and did not match the training certificates observed in the files. A file was observed to not have a valid drivers license on file.

Resolution: Corrected: 2023-06-08

Two direct care staff have not completed all of their pre-service training.

Resolution: Corrected: 2023-06-08

A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.

Resolution: Corrected: 2023-06-08

One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.

Resolution: Corrected: 2023-06-09

One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.

Resolution: Corrected: 2023-06-08

Two direct care staff have not completed all of their pre-service training.

Resolution: Corrected: 2023-06-08

All staff files reviewed did not contain written knowledge and competency of the training material.

Resolution: Corrected: 2023-06-08

A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.

Resolution: Corrected: 2023-06-08

There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.

Resolution: Corrected: 2023-06-08

The Disaster and Emergency curriculum does not have the required components such as the location and use of the fire extinguishers and first aid equipment.

Resolution: Corrected: 2023-06-08

A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.

Resolution: Corrected: 2023-06-08

There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.

Resolution: Corrected: 2023-06-08

The Disaster and Emergency curriculum does not have the required components such as the location and use of the fire extinguishers and first aid equipment.

Resolution: Corrected: 2023-06-08

The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.

Resolution: Corrected: 2023-06-08

A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.

Resolution: Corrected: 2023-06-08

The training logs that were observed were not accurate and did not match the training certificates observed in the files. A file was observed to not have a valid drivers license on file.

Resolution: Corrected: 2023-06-08

One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.

Resolution: Corrected: 2023-06-09

One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.

Resolution: Corrected: 2023-06-08

Two direct care staff have not completed all of their pre-service training.

Resolution: Corrected: 2023-06-08

All staff files reviewed did not contain written knowledge and competency of the training material.

Resolution: Corrected: 2023-06-08

One of the files reviewed did not have any information regarding the relationship or approved/unapproved contact with the child regarding one of the birth parents.

Resolution: Corrected: 2023-06-08

All staff files reviewed did not contain written knowledge and competency of the training material.

Resolution: Corrected: 2023-06-08

The training logs that were observed were not accurate and did not match the training certificates observed in the files. A file was observed to not have a valid drivers license on file.

Resolution: Corrected: 2023-06-08

Two direct care staff have not completed all of their pre-service training.

Resolution: Corrected: 2023-06-08

One of the files reviewed did not have an updated notarized affidavit for a rehire. The affidavit in the file was from 2021 however the caregiver was rehiredd on 6/2022 and should have had an updated one.

Resolution: Corrected: 2023-06-09

The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.

Resolution: Corrected: 2023-06-08

There was no staffing plan provided that included the plan for ensuring ratio, hours of coverage and plans to ensure child saftey if back up caregivers are needed to implemented 1 on 1 supervision.

Resolution: Corrected: 2023-06-08

The Disaster and Emergency curriculum does not have the required components such as the location and use of the fire extinguishers and first aid equipment.

Resolution: Corrected: 2023-06-08

A staff member is listed on the organizational chart as the Treatment Director & the Associate Program Director however there is no Treatment Director job description in the file.

Resolution: Corrected: 2023-06-08

A caregiver did not complete the required hours of supervised child care and the completion date was not documented in the file. The start date of his supervised child care at Hearts with Hope was incorrect on the training log, the hours were verified by reviewing his schedule of worked hours.

Resolution: Corrected: 2023-06-08

The training logs that were observed were not accurate and did not match the training certificates observed in the files. A file was observed to not have a valid drivers license on file.

Resolution: Corrected: 2023-06-08

The Case Manager is performing the job responsibilities of a PLSP such as admissions assessments, discharge, and implementing restrictions prior to treatment director approval.

Resolution: Corrected: 2023-06-08

Children in care were observed to not have a toothbrush and not sufficient and adequate clothing, the child had long sleeve shirts and sweatpants.

Resolution: Corrected: 2023-05-22

Children in care were observed to not have a toothbrush and not sufficient and adequate clothing, the child had long sleeve shirts and sweatpants.

Resolution: Corrected: 2023-05-22

Children in care were observed to not have a toothbrush and not sufficient and adequate clothing, the child had long sleeve shirts and sweatpants.

Resolution: Corrected: 2023-05-22

Children in care were observed to not have a toothbrush and not sufficient and adequate clothing, the child had long sleeve shirts and sweatpants.

Resolution: Corrected: 2023-05-22

The annual summary log does not include the time the absence was discovered.

Resolution: Corrected: 2023-06-28

The annual summary log was not available upon request for review. It was requested at 4:30pm and was not recived until the exit of this inspection.

Resolution: Corrected at inspection

The annual summary log was not available upon request for review. It was requested at 4:30pm and was not recived until the exit of this inspection.

Resolution: Corrected at inspection

The annual summary log does not include the time the absence was discovered.

Resolution: Corrected: 2023-06-28

The annual summary log was not available upon request for review. It was requested at 4:30pm and was not recived until the exit of this inspection.

Resolution: Corrected at inspection

The annual summary log does not include the time the absence was discovered.

Resolution: Corrected: 2023-06-28

The annual summary log was not available upon request for review. It was requested at 4:30pm and was not recived until the exit of this inspection.

Resolution: Corrected at inspection

The annual summary log does not include the time the absence was discovered.

Resolution: Corrected: 2023-06-28

Three out of five kids interviewed disclosed physical discipline was used in the facility by a staff.

Resolution: Corrected: 2023-04-21

Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.

Resolution: Corrected: 2023-04-21

Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.

Resolution: Corrected: 2023-04-21

Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.

Resolution: Corrected: 2023-04-21

Three out of five kids interviewed disclosed physical discipline was used in the facility by a staff.

Resolution: Corrected: 2023-04-21

Three out of five kids interviewed disclosed physical discipline was used in the facility by a staff.

Resolution: Corrected: 2023-04-21

Three out of five kids interviewed disclosed physical discipline was used in the facility by a staff.

Resolution: Corrected: 2023-04-21

Four out of five kids interviewed disclosed staff has yelled at and used vulgar language in their presence.

Resolution: Corrected: 2023-04-21

The operation did not notify licensing of a child's AWOL within the 6 hour time frame.

Resolution: Corrected: 2022-09-22

The operation did not notify licensing of a child's AWOL within the 6 hour time frame.

Resolution: Corrected: 2022-09-22

The operation did not notify licensing of a child's AWOL within the 6 hour time frame.

Resolution: Corrected: 2022-09-22

The operation did not notify licensing of a child's AWOL within the 6 hour time frame.

Resolution: Corrected: 2022-09-22

Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.

Resolution: Corrected: 2022-06-03

The victim's service plan states, "Due to the victim's intense level of care and unpredictable behaviors, she may receive 1:1 supervision when her behaviors warrant." When the staff arrived to assist with the situation, instead of staying to assist the caregiver that was already there to provide 1:1 supervision, the staff left, leaving the other staff to handle the situation alone with 2 other children in care that were receiving dental treatments.

Resolution: Corrected: 2022-06-03

Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.

Resolution: Corrected: 2022-06-03

The victim's service plan states, "Due to the victim's intense level of care and unpredictable behaviors, she may receive 1:1 supervision when her behaviors warrant." When the staff arrived to assist with the situation, instead of staying to assist the caregiver that was already there to provide 1:1 supervision, the staff left, leaving the other staff to handle the situation alone with 2 other children in care that were receiving dental treatments.

Resolution: Corrected: 2022-06-03

The victim's service plan states, "Due to the victim's intense level of care and unpredictable behaviors, she may receive 1:1 supervision when her behaviors warrant." When the staff arrived to assist with the situation, instead of staying to assist the caregiver that was already there to provide 1:1 supervision, the staff left, leaving the other staff to handle the situation alone with 2 other children in care that were receiving dental treatments.

Resolution: Corrected: 2022-06-03

Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.

Resolution: Corrected: 2022-06-03

Caregivers did not demonstrate prudent judgement when they left a child in care at the dentist office when she refused to get inside the vehicle. A caregiver arrived to assist but instead of staying and helping with the situation, the caregiver left.

Resolution: Corrected: 2022-06-03

The victim's service plan states, "Due to the victim's intense level of care and unpredictable behaviors, she may receive 1:1 supervision when her behaviors warrant." When the staff arrived to assist with the situation, instead of staying to assist the caregiver that was already there to provide 1:1 supervision, the staff left, leaving the other staff to handle the situation alone with 2 other children in care that were receiving dental treatments.

Resolution: Corrected: 2022-06-03

The operation failed to report a child made allegations of a staff member allegedly using drugs.

Resolution: Corrected: 2022-04-15

The operation failed to report a child made allegations of a staff member allegedly using drugs.

Resolution: Corrected: 2022-04-15

The operation failed to report a child made allegations of a staff member allegedly using drugs.

Resolution: Corrected: 2022-04-15

The operation failed to report a child made allegations of a staff member allegedly using drugs.

Resolution: Corrected: 2022-04-15

Reviewing unauthorized absence log on date 10/25/2021 & 12/11/2021 it was noted that debriefing was not conducted as well as time/ date was not entered into the form on 12/11/2021

Resolution: Corrected: 2022-02-28

Reviewing unauthorized absence log on date 10/25/2021 & 12/11/2021 it was noted that debriefing was not conducted as well as time/ date was not entered into the form on 12/11/2021

Resolution: Corrected: 2022-02-28

Reviewing unauthorized absence log on date 10/25/2021 & 12/11/2021 it was noted that debriefing was not conducted as well as time/ date was not entered into the form on 12/11/2021

Resolution: Corrected: 2022-02-28

Reviewing unauthorized absence log on date 10/25/2021 & 12/11/2021 it was noted that debriefing was not conducted as well as time/ date was not entered into the form on 12/11/2021

Resolution: Corrected: 2022-02-28

During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.

Resolution: Corrected: 2022-01-17

During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.

Resolution: Corrected: 2022-01-17

During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.

Resolution: Corrected: 2022-01-17

During a restraint a child in care was carried up the stairs which is not a permitted type of EBI.

Resolution: Corrected: 2022-01-17

One child had her morning medication administered however was not documented. Other medication logs were observed to not have been completed to it's entirety or showing details when medication was sent home with the child when they go on home visits.

Resolution: Corrected: 2021-07-20

Multiple medication records were observed to not have documented the reason the medication was prescribed.

Resolution: Corrected: 2021-07-20

One child had her morning medication administered however was not documented. Other medication logs were observed to not have been completed to it's entirety or showing details when medication was sent home with the child when they go on home visits.

Resolution: Corrected: 2021-07-20

Multiple medication records were observed to not have documented the reason the medication was prescribed.

Resolution: Corrected: 2021-07-20

Multiple medication records were observed to not have documented the reason the medication was prescribed.

Resolution: Corrected: 2021-07-20

Multiple medication records were observed to not have documented the reason the medication was prescribed.

Resolution: Corrected: 2021-07-20

One child had her morning medication administered however was not documented. Other medication logs were observed to not have been completed to it's entirety or showing details when medication was sent home with the child when they go on home visits.

Resolution: Corrected: 2021-07-20

One child had her morning medication administered however was not documented. Other medication logs were observed to not have been completed to it's entirety or showing details when medication was sent home with the child when they go on home visits.

Resolution: Corrected: 2021-07-20