Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00210752 Renewal 09/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 9/2/22, the water temperature was taken from the bathroom sink at 11:39 AM and measured 125.9 Degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The maintenance man will do monthly water checks (more if needed) for each house of thoughtful needs. Each month, the maintenance man will record the temperature on a water temperature form for each home. [Monthly water temperature log completed for September 2022 received on 9/30/22 and reviewed on 10/12/22. Documented water temperatures do not exceed 120 degrees Fahrenheit. DPOC by HDKP, HSLS, on 10/12/22]. 09/09/2022 Implemented
6400.72(a)On 9/2/22, the window located above Individual #2's, date of admission 4/20/2018, bed did not contain a screen. The window is operable and can be opened.Windows, including windows in doors, shall be securely screened when windows or doors are open. During the All staff meeting on 9/5/2022, management discussed repairs and hazards with the employees and explained that all repairs and/or hazards need to be reported immediately by completing the Maintenance Request Form and bringing it to the office manager. The maintenance man has ordered the screens for the windows. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of repairs and hazards, as well as how to complete the maintenance repair sheet and how to submit repair request received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/13/2022 Implemented
6400.32(r)On 9/2/22, Individual #1's, date of admission 9/07/2018, bedroom door does not have a lock and a lock declination page was not available. On 9/2/22, Individual #2's, date of admission 4/20/2018, bedroom door does not have a lock and a lock declination page was not available.An individual has the right to lock the individual's bedroom door.Thoughtful Needs has put two check boxes on the Individual Rights signature page that gives them the option to check if they want a lock or if they choose to not have a lock. If at any time he/she changes his/her mind, we will adjust accordingly. [Individual and Civil Rights form updated to include the option to indicate individual preference for a lock to be reviewed at least annually with every individual receiving services was received on 9/30/22 and reviewed 10/12/22. DPOC by HDKP, HSLS on 10/12/22]. 09/09/2022 Implemented
SIN-00193807 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Program Specialist #1, hired on 08/02/21, had a Pennsylvania State Police Criminal Background Check completed on 09/27/21An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. - Thoughtful Needs will create an employee database spreadsheet. All employees will be in the entered in the spreadsheet with completed information. - Every new hire will be added to the spreadsheet and all of his/her needed information/dates will be entered and tracked as well. 10/07/2021 Implemented
6400.21(d)A copy of Program Specialist #1's Pennsylvania State Police Criminal Background Check completed on 09/27/21 was not retained.A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept. -Thoughtful Needs will create an employee database spreadsheet. All employees will be in the entered in the spreadsheet with completed information. -Every new hire will be added to the spreadsheet and all of his/her needed information/dates will be entered and tracked as well. 10/07/2021 Implemented
6400.106The home's furnace was inspected and cleaned on 05/01/20 and then again on 05/25/21.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Maintenance will now take care of all yearly furnace inspections. Maintenance has entered the yearly date in his google calendar and also entered a date as a reminder to schedule an appointment for the inspection. 10/06/2021 Implemented
SIN-00178809 Renewal 10/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)Individual #1's physical examination completed 9/5/20 did not include the need for blood work. This section was left 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. All yearly physical examinations completed will be checked by both the Direct Care Staff and/or the Program Specialist to make sure that the doctor indicates the need for blood work. Direct Care Staff has been and will continue to be trained on the information that should be obtained during the individual¿s yearly physical before leaving the appointment. [Immediately, the CEO or designee shall contact Individual #1's health care provider to determine if Individual #1 needs blood work and follow medical orders as needed. Documentation of the aforementioned trainings of Direct Service Workers shall be kept. Documentation of aforementioned audits shall be kept. (DPOC by AES,HSLS on 12/22/20)] 11/23/2020 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 12/01/19. The rights document did not include the following rights: 6400.32a, to not be discriminated against based upon protected classes; 6400.32d through 6400.32g, to be treated with dignity and respect, choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j, to voice concerns about services; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, locking doors in bedrooms and in the home, access to food at any time, and making healthcare decisions.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.A new Individual Rights policy and procedure had been created according to the 6400 regulations. The Program Specialist have reviewed this policy with every individual, had him/her sign the policy and gave them a copy to keep. I will send the signed copy from this individual.[Individual #1 signed the updated individual rights documentation on 11/2/2020, copy provided to the Department on 11/25/2020. (AES,HSLS on 12/22/20)] 11/02/2020 Implemented
6400.165(g)Individual #1 has been prescribed medication to treat symptoms of Bipolar Affective Disorder. The review of medications prescribed to treat symptoms of a psychiatric diagnoses completed 5/4/20 did not include the need to continue medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.All medications that are prescribed from the doctor will be double checked by both the Direct Care Staff and/or the Program Specialist before leaving the appointment or when receiving the information through a telehealth call will make sure it includes the reason for prescribing, the need to continue medication and the necessary dosage. Direct Care Staff has been and will continue to be trained to make sure the information is included on the sheet before leaving the office. [Documentation of the aforementioned trainings of Direct Service Workers shall be kept. Documentation of aforementioned audits shall be kept to ensure individuals are administered medications as prescribed (DPOC by AES,HSLS on 12/22/20)] 11/23/2020 Implemented
SIN-00157230 Renewal 06/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain scissors. 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. On 06/14/2019, the scissors were located at the residence and placed in the First Aid kit before the end of the morning work shift (7am to 3pm). Home managers will verify the first aid inventory during random site inspections, and/or at least once per week. [Immediately and upon hire, the CEO or designee shall educate all staff persons including house managers of the required items in first aid kits and their responsibilities to ensure all items are included in first aid kits at all time. Documentation of the training shall be kept. (DPOC by AES,HSLS on 6/27/19)] 06/14/2019 Implemented
6400.151(a)Direct Service Worker #1, date of hire 02/07/19, had a physical examination completed 02/12/19. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Thoughtful Needs policy states that a physical needs to be completed before a person can be hired as staff. The staff, Direct Service Worker #1., completed her physical on 02/06/2019 and it was signed by a physician. On 02/07/2019, Direct Service Worker #1. was officially hired as a direct care staff by the previous Program Director. Direct Service Worker #1 met the staff physical exam requirements.The physical exam that was updated and signed on 02/12/2019 (the physical exam that was reviewed on 06/13/2019), was at the request of Lisa Culp, the owner of Thoughtful Needs and a nurse. Once Lisa returned to the office, she noticed that Direct Service Worker #1 had Oxycodone in her urine test. Direct Service Worker #1 was prescribed Oxycodone by her primary care physician. Lisa requested that Direct Service Worker #1 get documentation from her doctor that stated why she was prescribed the medication, as a safe guard for legal reasons. Direct Service Worker #1 received information from her primary care doctor. Direct Service Worker #1 met with physician, that completed the original physical exam on 02/06/19. Physician added the ¿updated comments¿ to the original physical exam and put the date the ¿updated comments¿ were added, 02/12/19. [Immediately and upon completion a designated staff person educated in staff persons physical examinations shall audit all staff persons' current physical examinations to ensure timely completion. Documentation of audits shall be kept. (DPOC by AES, HSLS on 7/27/19)] 06/25/2019 Implemented
SIN-00197441 Unannounced Monitoring 12/06/2021 Compliant - Finalized
SIN-00136726 Renewal 06/15/2018 Compliant - Finalized