Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249207 Renewal 08/06/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(i)The bedroom to the left of the hallway at the top of the stairs did not have drapes, curtains, shades, blinds, or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Maintenance installed a blind on 8/20/2024 08/20/2024 Not Implemented
SIN-00244985 Unannounced Monitoring 04/30/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)On 5/01/2024, there was a trash receptable in the kitchen of the home that was approximately 25 inches high with no 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 ensure 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]. 05/14/2024 Not Implemented
6400.64(f)On 5/01/2024, there was a trash receptable on the back porch of the home that was full of garbage with no lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Removed the garbage can that didn't have a lid and was replaced with a garbage can with 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]. 06/04/2024 Not Implemented
6400.72(a)On 5/01/2024, Individual #1's bedroom window was not securely screened. The window located in the dining room directly across from the kitchen was not securely screened.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screens was installed 06/03/2024 Accepted
6400.81(i)On 5/01/2024, Individual #2's bedroom has two windows with no drapes, curtains, shades, blinds or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Frost was installed on the individuals window to ensure privacy. [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
6400.32(l)During an interview that was completed with Individual #1 on 5/01/2024, it was stated that Individual #1 has to ask Chief Executive Officer #1 if they are allowed to receive visitors or meet privately with whom the individual chooses, and they are often denied.An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time.An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time, unless the individual has a restriction. 06/03/2024 Implemented
6400.163(h)Individual #2 was prescribed Ofloxacin Drops 0.3% with directions to instill five drops in the right eat twice a day for ear infection for 10 days on 10/28/2022. This medication was discontinued on 11/06/2022 but was still present in the medication box on 5/01/2024.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The medication was removed from the medication box immediately after. 05/20/2024 Implemented
6400.166(a)(6)Individual #2 is prescribed Lithium Carb Cap 300 MG with directions to take two capsules by mouth (600 MG) twice a day for bipolar disorder and to take with food. The April 2024 Medication Administration Record states to take two tablets by mouth twice a day for bipolar disorder.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.The MAR was changed to Lithium Carb cap 300mg Take two capsules (600) by mouth twice a day for bipolar disorder. But the take with food was not enter because the order from the doctor does not state take with food. 06/03/2024 Implemented
SIN-00229743 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)On 8/23/23, located in the basement of the home was a 13-gallon trash can that did not have a lid.Trash receptacles over 18 inches high shall have lids. A new trash can with a lid was purchased and replaced the one without the lid. 08/25/2023 Implemented
6400.110(a)On 8/23/23, the attic of the home did not have a smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. A fire alarm was temporarily installed in the attic until the interconnected alarms arrive for the house. 08/30/2023 Implemented
SIN-00210753 Renewal 09/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill completed on 12/16/2021 at 11:44 AM is missing the amount of time it took for evacuation. This section of the fire drill form was blank. [Repeat violation 9/28/2021, et. al.]A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. After assigning the date and hypothetical location of fire, the house manager will collect the fire drill and review to make sure that it is completed. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of fire drills documentation requirements, including the requirement to alternate evacuation routes, received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/13/2022 Implemented
6400.112(f)All fire drills completed between October 2021 - August 2022 used the front door as the exit route. Alternate exit routes need to be used during fire drills. The home has more than one exit.Alternate exit routes shall be used during fire drills. Thoughtful Needs had an all staff meeting and discussed fire drills and evacuation routes. The house manager will assign dates for the monthly fire drills and give each home a hypothetical scenario. This will ensure that the homes use alternative routes. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of fire drills documentation requirements, including the requirement to alternate evacuation routes, received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.141(c)(15)Individual #1, date of admission 5/11/2022, had a physical examination on 5/11/2022; however, the special instructions for the individual's diet assessment was not addressed. This section of the physical examination was left blank.The physical examination shall include:Special instructions for the individual's diet. Prior to becoming a resident at Thoughtful Needs, all individuals will be given our physical form that will need completed before his/her first day. Once the individual is established and going for his/her routine physical, the form will be supplied to the doctor to complete, the staff will bring the form to the Program Specialist, or it will be faxed from the doctor once it is fully completed. Once the Program Specialist receives the physical form, it will be reviewed to ensure it is complete. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of doctor appointments, consultation forms, and ensuring that appointment documentation is completed was received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/09/2022 Implemented
6400.166(b)The following medications prescribed for Individual #1, date of admission 5/11/2022, were not recorded in the medication record at the time the medication was administered on 9/02/2022 at 8:00 AM: CLONAZEPAM TAB 1 MG - Take 1 tablet three times a day for mood d/o. COMPOUND W LIQ 17% - Apply topically to wart daily for wart removal. METFORMIN TAB 500 MG - Take 2 tablets by mouth daily for diabetes. OLOPATADINE SOL 0.2% - Instill 1 drop into both eyes daily for allergies. OXCARBAZEPIN TAB 150 MG - Take 1 tablet by mouth twice a day for mood d/o. OXCARBAZEPIN TAB 600 MG - Take 1 & 1/2 tablets (900 MG) by mouth twice a day for mood d/o. RISPERIDONE TAB 3 MG - Take 1 tablet three by mouth times a day for mood d/o. SERTRALINE TAB 50 MG - Take 1 & 1/2 tablets (75 MG) by mouth daily for depression. VITAMIN B12 500 MCG TABS - Take 1 tablet by mouth daily for b12 deficiency. BENZOYL PER LIQ 10% WASH - Wash face daily for acne. CLINDAMYCIN LOT 1% - Apply topically to affected area daily for acne. [Repeat violation 9/28/2021, et. al.]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.There was an all staff meeting on September 6, 2022, and medication were discussed. The medication trainer explained the importance of giving medications properly and signing off on the medications at the time they are administered. The nurse will check the MAR daily to make sure all meds were administered and signed off on. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of medications administered timely, documenting administration immediately, and reporting of any issues was received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
SIN-00193808 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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
6400.112(c)The amount of time it took to evacuate the home was not recorded for the following fire drills held on 12/15/20, 03/23/21, 05/13/21, and 06/01/21A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. - Thoughtful Needs Program Specialists will collect the Fire Drill Forms every month from each home by the 25th to ensure time to redo if needed.. - After picking up the forms, each form will be thoroughly checked by the Program Specialist. - Upon completion of the check, they will be placed in the specific home binder which will be kept in the office. 10/05/2021 Implemented
6400.166(a)(11)The following medications did not include a diagnosis or purpose on Individual #1's September 2021 Medication Administration Record: Benzatropine tab 1 mg- 8AM/8PM- Take 1 tablet by mouth twice a day Cephalexin Capsule 500 mg- Take 1 capsule by mouth four times a day Metformin Tab 1000 mg- Take 1 tablet by mouth twice a day in the morning and evening with meals Metoprolol Tartrate Tablet 25 mg- Take 1 tablet by mouth twice a day NYAMYC Powder- AT to affected area of abdomen three times a day Pantoprazole Tablet 40 mg- Take 1 tablet by mouth twice a day Pravastatin Tablet 20 mg- Take 1 tablet by mouth daily Tamsulosin .4g- Take 1 capsule by mouth daily Trazodone Tab 50 mg- Take 1 tablet by mouth at bedtime Vitamin D3 Capsule 1,000 IU- Take 1 tablet by mouth dailyA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.- The pharmacy was contacted and will begin including the diagnosis/purpose on all new medications. - In-order for the Pharmacy to know the doctors diagnosis/purpose the medication monitoring will be sent with every e-script. - All information will be entered into the MAR 09/29/2021 Implemented
SIN-00178810 Renewal 10/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1 was informed and explained individual rights on 02/18/20. 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 will review this policy with [Individual #1] upon his return to Thoughtful Needs. [Individual #1 was informed and explained individual rights and signed the updated rights document which included the updated rights on 12/21/2020. (AES,HSLS on 12/24/20)] 11/02/2020 Implemented
6400.165(g)Individual #1 is prescribed medications to treat symptoms of Adjustment Disorder with depressed mood, Attention Deficit Hyperactivity Disorder, and Disruptive Mood Dysregulation Disorder. The review of medications used to treat symptoms of psychiatric illness completed 8/13/20 did not include the necessary dosage of medication.The review of medications used to treat symptoms of psychiatric illness completed 5/18/20 did not include the medication or the necessary dosage.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
6400.213(1)(i)The record for Individual #1 did not include the individual's means of communication.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.All vital record information sheets were updated and now include both the means of communication and identifying marks for every individual. I will send the Vital Sheet. [Individual #1's record (documentation titled "Vital Information Sheet/personal information" was updated to include "Primary Language/English" on 12/21/20, copy provided to the Department on 12/23/2020. Immediately and at least quarterly, the CEO or a designated staff persons educated in the requirements of individual records shall audit all individual records to ensure all required information is included and up to date. (AES,HSLS on 12/24/20)] 11/02/2020 Implemented
SIN-00157231 Renewal 06/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At 9:50 AM, water was leaking through the living room ceiling from the sink on the second floor causing a puddle on the living room floor, posing a slipping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The landlord was contacted on 06/14/2019 regarding the water leaking from the living room ceiling. The landlord sent his maintenance company, Superior Companies Inc., to make repairs. On 06/14/2019, the toilet flange and the toilet wax ring were replaced in the bathroom above the living room. On 06/24/2019, the living room ceiling was repaired and repainted. Thoughtful Needs will do a monthly inspection of all residential sites, to identify any repair issues. The residential staff will complete a repair request slip for any repairs needed, once an issue is identified. Thoughtful Needs will complete the repairs in a reasonable about of time. Thoughtful Needs will contact Superior Companies Inc., if any major repairs are needed. [Immediately, the CEO or designee shall educate all staff persons working in community homes of the agencies procedures to complete physical site checks and identify needed repairs and reporting to ensure timely completion of repairs. Documentation of the trainings shall be kept. Documentation of aforementioned monthly physical site inspections of the homes shall be kept. (DPOC by AES,HSLS on 6/27/19)] 06/24/2019 Implemented
6400.72(b)The handle on the screen door leading from the basement on the side of the home was broken, preventing the screen door from closing and latching. The screen door closer was detached from the screen and hanging from the door jamb. Screens, windows and doors shall be in good repair. The screen door was repaired on 06/17/2019. The closing cylinder was purchased and attached to the middle of the screen door. A new safety chain was attached to the top of the screen door. A new lock was added to the basement main door. The old lock made the door hard to open. A new hand rail was also added due to the steps outside the basement door. Thoughtful Needs will do a monthly inspection of all residential sites, to identify any repair issues. The residential staff will complete a repair request slip for any repairs needed, once an issue is identified. Thoughtful Needs will complete the repairs in a reasonable about of time. Thoughtful Needs will contact Superior Companies Inc., if any major repairs are needed.[Immediately, the CEO or designee shall educate all staff persons working in community homes of the agencies procedures to complete physical site checks and identify needed repairs and reporting to ensure timely completion of repairs. Documentation of the trainings shall be kept. Documentation of aforementioned monthly physical site inspections of the homes shall be kept. (DPOC by AES,HSLS on 6/27/19)] 06/17/2019 Implemented
6400.110(e)The smoke detectors in the basement, on the main level, and on the second floor of the home were not interconnectedIf the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. On 06/14/2019, the landlord was contacted because the interconnected smoke alarms were not working. The smoke alarms are hard wired into the ceiling of the home. On 06/24/2019, the Superior Companies Inc. fixed the issue with the interconnected smoke alarm. Superior Companies Inc. tested the system several times to verify it was working correctly. The residential staff will conduct fire drills in conjunction with the local fire department as well as monthly fire drills. [Immediately, the CEO or designee shall educate all staff persons working in community homes of their responsibilities of conducting unannounced monthly fire drills and testing and using the interconnected smoke detectors. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 6/27/19)] 06/24/2019 Implemented
SIN-00197444 Unannounced Monitoring 12/06/2021 Compliant - Finalized