Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258362 Renewal 01/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.75(a)On 1/8/2025 at 10:58am, the door in the kitchen that leads to the basement stair well was observed with a door that swings toward the stairwell and opens directly onto the stairs. No landing was observed.A landing shall be provided beyond each interior and exterior door that opens directly into a stairway. The maintenance removed the door on 1/08/2025, and also checked all other agencies homes to ensure this regulation is implemented throughout all homes if there is a door that opens directly into a stairway. 01/08/2025 Implemented
6400.214(b)Individual #1's assessment that was available on-site at the residential home, through Therap, was completed on 12/27/2023. The most current assessment available in Individual #1's record was completed on 12/26/2024. Individual #1's dental examination that was available on-site at the residential home, through Therap, was completed on 12/7/2023. The most current dental examination available in Individual #1's record was completed on 11/21/2024. [Repeated violation: 11/21/2024 et al] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The program specialist updated Therap with the current records on 1/13/2025 01/13/2025 Implemented
6400.15(b)The self-assessments completed on 5/23/2024, 11/23/2024, and 12/28/2024 were completed on the 6400 Scoresheet that was last updated in June 2018. This scoresheet does not measure compliance with all the current 6400 regulations.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency will immediately (1/8/2025) transition to using the Department's licensing inspection instrument for community homes to measure and record compliance, The outdated scoresheet used on 5/23/2024, 11/23/2024, and 12/28/2024 will no longer be utilized. 01/08/2025 Implemented
6400.165(g)Individual #1's psychiatric medication reviews were completed on 4/12/2024 and 7/19/2024.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.The nurses will take a calendar with them to appointments to make sure they are scheduling appoints in the right time frame. 01/08/2025 Implemented
SIN-00256180 Unannounced Monitoring 11/21/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66On 11/21/2024 at 11:45am, there was no operable light source observed in the basement storage room at the front of the house. There was a light fixture on the ceiling of this room; however, no light bulb was observed in the fixture at the time of the inspection. [Repeated violation: 4/30/2024 et al and 8/6/2024 et al]Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A lightbulb was immediately installed on 11/21/24 11/21/2024 Implemented
6400.81(k)(6)On 11/21/2024 at 11:32am, a mirror was not present in Individual #1's bedroom. Individual #1's Support Plan, last updated 11/5/2024, does not indicate that the individual chose not to have a mirror in their bedroom. On 11/21/2024 at 11:35am, a mirror was not present in Individual #2's bedroom. Individual #2's Support Plan, last updated 10/29/2024, does not indicate that the individual chose not to have a mirror in their bedroom. During conversations with Individual #2, the individual disclosed to licensing personnel that they would like to have mirror in their bedroom; however, his mirror was not moved to this home when he moved out of his previous residence.In bedrooms, each individual shall have the following: A mirror. Non-breakable mirrors were ordered on 11/21/2024 and installed on 11/25/2024 11/25/2024 Implemented
6400.214(b)On 11/21/2024 at 12:30pm, the following documents from Individual #2's record were not available on-site at the residence: current Individualized Support Plan, current assessment, current physical examination, and current dental examination. On 11/21/2024 at 12:35pm, the following documents from Individual #3's record were not available on-site at the residence: current assessment and current dental examination. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. All documents for both Individual 2# and individual 3# were uploaded immediately on 11/21/2024 11/21/2024 Implemented
SIN-00253083 Unannounced Monitoring 09/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Direct Service Workers #1 and #2 neglected to provide the needed care to Individual #1. On 9/22/2024, Direct Service Worker #2 arrived for their 3:00pm -- 11:00pm shift. While on the clock, Direct Service Worker #2 purchased alcohol at a local convenience store and drank the alcoholic beverages. Direct Service Worker #2 became intoxicated while on the job and was unable to properly care for Individual #1. Direct Service Worker #1 witnessed Direct Service Worker #2 drinking and becoming intoxicated while on shift and did not report the incidents of neglect. While intoxicated, Direct Service Worker #2 failed to administer Individual #1's medications as prescribed, failed to provide Individual #1 with dinner, and left individual #1 unattended in the agency vehicle when he is required to have 1:1 supervision 24 hours per day. Additionally, while at another home that is operated by the agency, Direct Service Worker #2 forced Individual #2 to walk through the home, into the community, and onto the agency van while wearing only an incontinence brief.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.DSP # 2 was immediately terminated on-site 9/22/24, DSP #1 was immediately retrained by the director on incident management on 9/23/24. 09/23/2024 Implemented
6400.63(a)On 9/27/2024 at 11:03am, the water temperature at the kitchen sink measured 125.4°F. On 9/27/2024 at 11:06am, the water temperature at the bathroom sink measured 123.2°F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Maintenance ordered anti-scald devices on Oct 11,2024. They will be delivered Oct 21-22. Maintenance will immediately install the devices on faucets to regulate water temperature by Oct 25, 2024 10/25/2024 Implemented
6400.64(e)On 9/27/2024 at 11:22am, a trash can, measuring more than eighteen-inches in height was observed without a lid in individual #3's bedroom. [Repeat violation: 4/30/2024 et al]Trash receptacles over 18 inches high shall have lids. The trash can lid is securely attached to the tote and functions correctly 09/27/2024 09/27/2024 Implemented
6400.18(g)Enterprise Incident Management Incident #9490333 was discovered by the agency on 9/22/2024 at 8:17pm. Certified investigator #5 was assigned to complete the investigation on 9/23/2024 at 9:00am. The first witness interview was conducted by Certified Investigator #5 on 9/24/2024 at 12:07pm.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.Incident manager retrained on CI Manual 10/14/2024 10/14/2024 Implemented
6400.32(c)On 9/22/2024 during the 3:00pm -- 11:00pm staffing shift, Individual #1 was taken to another community home that is operated by the agency. While at the other home, Individual #1 was forced to witness verbal and physical altercations between Direct Service Worker #2 and Direct Service Worker #3. According to witness testimony, Direct Service Worker #2 was observed yelling at and seen pushing Direct Service Worker #3.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.DSP #2 was terminated on-site 9/22/2024 09/22/2024 Implemented
6400.32(d)On 9/22/2024 during the 3:00pm -- 11:00pm staffing shift, Individual #1 was taken to another community home that is operated by the agency. While at the other home, Individual #1 required assistance in the restroom. Direct Service Worker #2 assisted Individual #1 in the restroom and then allowed him to walk through the home wearing only an incontinence brief. Individual #1 was then walked through the community and onto the agency vehicle while only wearing an incontinence brief. By not providing Individual #1 with proper clothing, the agency violated Individual #1's right to be treated with dignity and respect. [Repeat violation: 4/30/2024 et al]An individual shall be treated with dignity and respect.HR has revised the dignity and respect policy on 10/09/2024, with immediate termination for any violations, effective immediately. 10/09/2024 Implemented
6400.45(d)Individual #1's support plan, last updated 5/16/2024, indicates that "[Individual #1] REQUIRES 24 HOUR AWAKE STAFF AT THE COMMUNITY HOME···HE REQUIRES AT A MINIMUM 1:1 STAFFING···[Individual #1] REQUIRES CLOSE SUPERVISION IN THE COMMUNITY AT ALL TIMES." On 9/22/2024 at approximately 8:50pm, Direct Service Worker #2 left Individual #1 unattended in the agency vehicle while it was parked in the driveway of the home.The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ).The director will conduct a mandatory training on November 8th,11th, and 12th to retrain all DSP'S on chapter 6400.45 (e) 11/12/2024 Implemented
6400.45(e)On 9/22/2024, Individual #2 was to be picked up from his girlfriend's house at 8:00pm by Direct Service Workers #1 and #2. At 8:17pm on 9/22/2024, Direct Service Workers #1 and #2 had not arrived to pick up Individual #2. Individual #2 then contacted Compliance Coordinator #4, who picked him up at approximately 8:50pm. During the time when Direct Service Workers #1 and #2 were to pick up Individual #2, Direct Service Worker #2 chose to go to another home that is operated by the agency to have a personal conversation with Direct Service Worker #3. Individual #2 was left unsupervised for approximately 50 minutes at his girlfriend's home solely for the convenience of Direct Service Worker #2.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.The director will conduct a mandatory training on November 8th,11th, and 12th to retrain all DSP'S on chapter 6400.45 (e) 11/12/2024 Implemented
6400.50(a)Direct Service Worker #1 participated in trainings on the implementation of the individual plans for Individuals #1, #2, and #3 on 9/11/2024. These training records did not include the length of trainings.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The orientation check list was updated to include the length of the individual's support plans training, on 10/09/2024 10/09/2024 Implemented
6400.165(c)Individual #1 is prescribed Oxcarbazepine 600mg tab. On 9/22/2024, the 5:00pm does was not administered to Individual #1. The agency failed to follow the physician's order and administer the medication as prescribed.A prescription medication shall be administered as prescribed.All DSP's will have a refresher of medication administration on November 8th, 11th, and 12th. 11/12/2024 Implemented
6400.166(b)Individual #1 is prescribed Polyeth GLYC POW 3350 NF and Risperidone 3mg tab, both to be administered daily at 8:00am. The September 2024 Medication Administration Record did not include the initials of the staff that administered these medications at 8:00am on 9/27/2024.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All DSP's will have a refresher of medication administration on November 8th, 11th, and 12th. 11/12/2024 Implemented
6400.167(a)(1)Individual #1 is prescribed Oxcarbazepine 600mg tab. On 9/22/2024, the 5:00pm does was not administered to Individual #1 resulting in a medication error for failing to administer a medication as prescribed. [Repeat violation: 4/30/2024 et al]Medication errors include the following: Failure to administer a medication.All DSP's will have a refresher of medication administration on November 8th, 11th, and 12th. 11/12/2024 Implemented
SIN-00244879 Unannounced Monitoring 04/30/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 5/1/2024, a plethora of poisonous materials were unlocked and accessible under the bathroom sink. The poisonous materials include, but are not limited to, Lysol Power Cleaning Gel, Great Value Multi-Purpose Cleaner, and a spray bottle of Oxi Clean. On 5/1/2024, a plethora of poisonous materials were unlocked and accessible under the kitchen sink. The poisonous materials include, but are not limited to, two bottles of Lysol All Purpose Cleaner, Fabuloso, and Heavy Duty Oven Cleaner. Individual #1's individual support plan last updated on 5/16/2024 states the individual has no safety skills regarding poisonous substances, and they are to be kept locked.Poisonous materials shall be kept locked or made inaccessible to individuals. All cleaning products are locked up in a cleaning cabinet in the basement. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 05/22/2024 Not Implemented
6400.62(c)On 5/1/2024, there was a bottle under the unlocked kitchen sink with an original label of Clorox Cleaner and Bleach. There was tape overtop of the original table with a handwritten label that states "Don't judge a book by its cover." The bottle contained an unknown liquid.Poisonous materials shall be stored in their original, labeled containers. Conducted a thorough review of our cleaning procedures and protocols to ensure compliance with safety and sanitation standards make sure all cleaning products are in their original containers. 05/20/2024 Implemented
6400.64(a)On 5/01/2024, clean and sanitary conditions were not maintained throughout the home. Individual #1's bedroom contained multiple opened bottles filled with chewing tobacco, a fan covered with dirt and debris, dirty clothes overflowing from the hamper and overflowing onto the floor, and a 13-gallon trash can filled with trash and did not have a lid. The two bathmats located outside of the shower in the bathroom were drenched and covered with debris. The toilet was filled with urine. The bottom of the shower was covered with soap scum and dirt. Individual #1's bed sheets and comforter had a large, wet urine spot in the center of the bed. The bedding was not changed after Individual #1 soiled their bed. Individual #3's bedroom floor contained multiple crushed up water bottles, two empty 1-gallon bottles of 2% milk, numerous food wrappers and an empty bag of Hawaiian rolls.Clean and sanitary conditions shall be maintained in the home. Staff cleaned up their rooms immediately. Program specialist will conduct assessments to identify the root cause of the cleanliness issues and develop personalized cleaning plans tailored to each individual's needs. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.64(e)On 5/1/2024, there was a trash can in Individual #2's bedroom filled with garbage that was approximately 25 inches tall and did not have a lid [Repeat violation 8/22/23, et. al.].Trash receptacles over 18 inches high shall have lids. Purchased all new garbage cans with lids, and ensured all lids were properly installed on the respective garbage cans immediately upon receipt. [During the unannounced monitoring inspection that occurred on 9/27/2024 this regulation was identified as non-compliance during home inspections. Therefore the POC could not be verified as implemented. DPOC by HDKP, HSLS, on 10/18/2024]. 06/06/2024 Not Implemented
6400.64(f)On 5/01/2024 there was an exterior trash receptable on the bottom step of the side entrance to the home that did not have a lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The exterior trash can was replaced with trash can with a lid. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 05/27/2024 Not Implemented
6400.67(a)On 5/01/2024, there was a doorknob sized hole in the wall located in Individual #1's wall behind their door. There were also two 1-inch holes in the wall above Individual #1's bed. The bathroom floor has cracked tile located directly to the right of the closet. The kitchen countertop has peel and stick vinyl paper. The vinyl paper appeared to have water damage and was coming off and in disrepair. There is a leak under the kitchen sink, causing the cabinet floor to be deteriorated and caving in. It also has an overpowering mildew smell.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance repaired the doorknob hole in the wall, patched all other holes in wall, and address the crack in the floor by the closet. The peeling vinyl on the countertops were replaced and the leak under the sink was promptly repaired to prevent further damages. Additionally, we did assess the and replaced deteriorated cabinet floor and reinforced them. The overpowering mildew smell, a thorough cleaning and disinfecting the areas was done, followed by measures to improve moisture control. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.67(b)On 5/01/2024 there was a puddle of water at the bottom of the stairs descending to the basement. Floors, walls, ceilings and other surfaces shall be free of hazards.The area was thoroughly cleaned, a dried and a dehumidifier was purchased to prevent any moisture on the basement floors. Maintenance will implement regular checks to monitor for any reoccurring issue. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.68(b)On 5/1/2024, at 10:44 AM, the hot water temperature was taken from the shower measured 123.8 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Maintenace promptly adjusted the water heater settings. [During the renewal inspection that occurred on 8/6-7/2024 training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.72(b)On 5/01/2024, there was approximately a 6-inch crack in the bathroom door located to the left of the door handle. The windowsill located below the bathroom window has approximately a 4-inch piece of wood that is missing [Repeat violation 8/22/23, et. al.]. Screens, windows and doors shall be in good repair. Maintenance replaced door and the missing wood in the window seal to restore structural integrity and to prevent further damage. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.76(a)On 5/01/2024, the cabinet located in Individual #3's bedroom only contains one out of three drawers. Individual #2's bedroom has an end table with two drawers and the top drawer is missing the handle. Furniture and equipment shall be nonhazardous, clean and sturdy. The drawers were placed back in the cabinet in the individual's bedroom. The individual's end table handle was fixed. 06/03/2024 Implemented
6400.80(b)On 5/01/2024, there was a drainage pipe located in the front yard that of the home that was twisted and mangled, causing a very sharp edge and a tripping hazard. There are multiple holes in the exterior siding of the garage, causing sharp edges. There were numerous cigarette butts located in the front and side yard of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Maintenance team replaced the drainage pipe to eliminate the sharp edges and tripping hazards, the holes in the garage siding was also repaired to removed sharp edges, a thorough cleaning of the yard was also done to remove cigarette butts and maintain a clean safe environment. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.82(f)On 5/01/2024, the bathroom of the home did not have individual clean paper or cloth towels.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. Hand towels were purchased and placed in the bathroom. 06/05/2024 Implemented
6400.101On 5/01/2024, the man door located in the garage was screwed shut. There was also a grill located directly in front of the door on the inside of the garage, causing the egress to be obstructed.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The garage door was unscrewed and made fully operational to ensure proper access and egress in case of emergency. The grill was promptly removed from blocking the inside of the door to eliminate any obstructions to exit routes. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.171On 5/01/2024, an opened box of uncovered instant mashed potatoes was found in the kitchen pantry. The following food items were found in the refrigerator on 5/01/2024, a glass container of molded blueberries with an opened date of 3/30/2024, a bag of molded shredded lettuce with a best by date of 4/08/2024, and an unopened container of bologna that contained mold. The garage has a deep freezer with multiple food items in zip locked bags that were unlabeled and unrecognizable due to being freezer burnt.Food shall be protected from contamination while being stored, prepared, transported and served. The refrigerator was cleaned and disinfected and all expired and moldy items were removed immediately. The freezer was also cleaned and all unlabeled and freezer burnt food was thrown away. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.32(h)Individual #1 was subject to audio and video recording in their home through 4/26/2024. Individual #2 was subject to audio and video recording in their home through 4/26/2024. Individual #3 was subject to audio and video recording in their home through 4/26/2024. The practice of audio and video recording was being utilized by the agency throughout all of their licensed residential homes.An individual has the right to privacy of person and possessions.The audio was immediately shut down to cease any further audio recording. All residents were informed about the incident and signed a new camera Policy/Procedure. 04/26/2024 Implemented
6400.163(d)On 5/1/2024, the following medications were located in the unlocked medicine cabinet: Panoxyl Acne Creamy Wash and OneTouch Delica Plus. The following medication was located in Individual #2's unlocked bedroom on top of their dresser: Wild Willies Beard Growth Supplement.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The medication cabinet must be locked at all times to prevent unauthorized access and ensure safety. Additionally, the beard growth supplement that was found on the bedroom top dresser was removed since there is no valid prescription. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
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-00249206 Renewal 08/06/2024 Compliant - Finalized
SIN-00197441 Unannounced Monitoring 12/06/2021 Compliant - Finalized
SIN-00136726 Renewal 06/15/2018 Compliant - Finalized