Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256181 Unannounced Monitoring 11/21/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66On 11/21/2024 at 1:55pm, the light fixture at the rear basement exit was observed inoperable and without a light bulb. The light fixture was no longer attached to the base and the electrical wiring was not connected to the fixture. [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. Maintenance staff were immediately notified, and a work order was submitted on November 21st, 2024. The light fixture was repaired, and lightbulb was installed the same day. 11/21/2024 Implemented
6400.72(b)On 11/21/2024 at 1:11pm, the screen in the kitchen window located above the stove was observed with a tear in the lower right corner that measured approximately four-inches wide. [Repeated violation: 4/30/2024 et al and 8/6/2024 et al] Screens, windows and doors shall be in good repair. Maintenance immediately fixed the screens on 11/21/2024 11/21/2024 Implemented
6400.80(b)On 11/21/2024 at 1:55pm, the light fixture at the rear basement exit was observed no longer attached to the base and the electrical wiring was exposed and no longer attached to the light fixture. The exposed wiring had the potential to harm an individual or staff if touched. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Maintenance staff were immediately notified, and a work order was submitted on November 21st, 2024. The light fixture was repaired, and lightbulb was installed the same day. 11/21/2024 Implemented
6400.214(b)On 11/21/2024 at 1:50pm, Individual #1's psychological evaluation was not available on-site in the residential home. Individual #1 had a psychological evaluation completed on 7/24/2024; however, this evaluation was only available at the agency office at the time of the inspection. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The evaluation was immediately uploaded to Therap 11/21/2024. 11/21/2024 Implemented
6400.18(a)(4)Enterprise Incident Management incident #9468833 was discovered on 8/16/2024 and had a due date for the incident first section of 8/17/2024 at 8:51pm. The incident first section was submitted by the agency on 8/19/2024 at 7:17am.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. Incidents must be submitted by via email, and each incident will be reported separately to ensure accuracy and clarity starting December 2 12/02/2024 Implemented
SIN-00229744 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 8/23/23 at 10:18 AM, the hot water measured 123.2 degrees Fahrenheit at the bathroom sink.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. The water was turned down and was checked to make sure that it was within the guidelines of the regulations of being below 120 degrees. When the temp was re-checked it was 117 degrees. 08/30/2023 Implemented
6400.72(b)On 8/23/23, the screen in the bathroom window had an approximate 1.5-inch tear in the bottom center of the screen. Screens, windows and doors shall be in good repair. The screen was brought into warehouse sales where it was replaced and put back into the bathroom window. 08/28/2023 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. Interconnecting smoke detectors have been orders and will be installed in the home once they are received. A smoke detector has been put in the attic until the interconnecting alarms arrive and are installed. 08/24/2023 Implemented
6400.110(e)On 8/23/23, the smoke detectors were not interconnected. The home is 3 stories.If 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. Interconnecting fire alarms were ordered and will be installed and tested as soon as they arrive. 08/30/2023 Implemented
6400.141(c)(4)Individual #1 had a vision screening 8/5/21 and then again 9/19/2022.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Program Specialist (Chad) created a sheet that contains a list of the each individual and their most recent appointment, annual dates for all yearly requirements that apply to the individual and the doctors name and phone number. 08/31/2023 Implemented
6400.181(e)(12)Individual #1's 9/8/22 assessment does not include Recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The line provided for recommendations for specific areas of training, programming and services had an X however Chad went back and wrote that the individual was not interested in any type of training or working. 08/31/2023 Implemented
6400.166(a)(5)Individual #! is prescribed Excedrin Tension Headache. The pharmacy label and the August 2023 medication administration record do not indicate the strength of the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.The nurse called the pharmacy immediately to ask for new medication that has the strength of the medication listed on the label and it was delivered the next morning. The medication that did not have the strength on it was discarded and the new corrected medication was put in the medication box. 08/24/0203 Implemented
SIN-00210754 Renewal 09/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)On 9/2/22, the basement floor was not free of hazards and was observed with a puddle, approximately 1 foot in diameter, at the bottom of the basement stairs. Floors, walls, ceilings and other surfaces shall be free of hazards.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. [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
6400.112(f)The fire drills conducted between October 2021 and August 2022 did not practice alternate exit routes. All drills utilized the front door as the exit route. 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
6400.32(r)On 9/2/22, Individual #1's, date of admission 11/27/2021, bedroom door does not have a lock and a lock declination page was not availableAn 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-00193809 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1,hired on 06/27/19, had a Pennsylvania State Police Criminal Background Check completed on 02/18/20.An 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
6400.77(b)The home's first aid kit did not include tweezers. 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. The First Aid kits in all houses will be checked weekly to makes sure all required items are available in case of any accident or injuries that may occur. 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 he also entered a date as a reminder to schedule an appointment for the inspection. 10/06/2021 Implemented
6400.166(a)(11)The following medications did not include a diagnosis or purpose on Individual #1's September 2021 Medication Administration Record: Desmopressin Tab .2 mg- take 2 tablets by mouth every night at bedtime. Divalproex Tab 500 mg- take 2 tablets (1000 mg) by mouth twice a day. Guanfacine Tab .2 mg- take 1 tablet by mouth every morning and at 2 PM. Levothyroxine 100 mcg- Take 1 tablet by mouth 30 minutes prior to eating in the morning. Melatonin Sub 5 mg- Take 2 tablets (10 mg) by mouth at bedtime *dissolve on tongue* Paroxetine 20 mg- take 1 tablet by mouth one time a day at 08 PM. Tamazepam 15 mg- Take 1 capsule by mouth at bedtime.A 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
6400.166(b)Individual #1 is prescribed Desmopressin Tab .2 mg- take 2 tablets by mouth every night at bedtime. The medication was not logged as administered in the Medication Administration Record on 09/26/21 at 8PM) Individual #1 is prescribed Paroxetine 20 mg- take 1 tablet by mouth one time a day at 08 PM. The medication was not logged as administered in the September 2021 Medication Administration Record on 09/27/29 @ 8 PM Individual #1 is prescribed Tamazepam 15 mg- Take 1 capsule by mouth at bedtime. The medication was not logged as administered in the September 2021 Medication Administration Record on 09/27/21.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Program Specialist(s) will monitor the MAR daily to make sure the night prior and current staff has logged the medications correctly. Staff will be called immediately to complete the MAR and a disciplinary action will follow. 10/08/2021 Implemented
SIN-00157232 Renewal 06/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1, date of admission 10/19/18, was informed of the individual's rights 12/01/18.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. Thoughtful Needs has adopted an intake checklist in order to make sure all of the required forms and information has been received. The checklist has a list of required information based on the PA 6400 regulations. The checklist will assist the Program Director and Program Specialist when an individual transfers from another provider or when an individual comes from a family home. The checklist will help reduce the chance of missing documents and missing signatures/dates. [Upon completion of the checklist for at least one year, the CEO or designee shall audit the completed checklist and review the intake process to ensure all individuals are informed of their rights timely and signed statement is maintained. Documentation of audits shall be kept. (DPOC by AES,HSLS on 6/27/19)] 06/14/2019 Implemented
6400.68(b)At 11:07 AM, the hot water temperature at the shower in the bathroom adjacent to the kitchen measured 130.2 degrees Fahrenheit Hot water temperatures in bathtubs and showers may not exceed 120°F. On June 14, 2019, the water heater was adjusted to reduce the temperature of the water around 2:00pm in the afternoon. The afternoon staff, 3:00pm to 11:00pm shift, took the temperature of the shower water around 8:00pm at night before the individual took her shower. The water temperature registered at 110 to 116 degrees. Staff are required to test the temperature of the water every time the individual requests to take a shower or bath. [Immediately, the CEO or designee shall educate all staff persons responsible for measuring water temperature of the agency's policy and procedures to include measuring, reporting, adjusting, documenting etc. to ensure the water temperature does not exceed 120°F at all bathtubs and showers at all community homes. Documentation of the trainings shall be kept. Documentation of the water temperature tests shall be kept and audits by designated management staff person to ensure completion and that the hot water temperature does not exceed 120°F. (DPOC by AES,HSLS on 6/27/19)] 06/14/2019 Implemented
6400.73(a)The four exterior steps leading from the basement of the home did not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 06/17/2019, a new hand rail was added due to the number of outside steps leaving the basement. A light bulb was placed by the outside basement steps. The light will assist the individual and staff at night. 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 to ensure the safety and welfare of the individuals receiving services.[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
6400.141(a)Individual #1, date of admission 10/19/18, had an initial physical examination completed 11/14/18.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Thoughtful Needs has adopted an intake checklist in order to make sure all of the required forms and information has been received. The checklist has a list of required information based on the PA 6400 regulations. The checklist will assist the Program Director and Program Specialist when an individual transfers from another provider or when an individual comes from a family home. The checklist will help reduce the chance of missing documents and missing signatures/dates. [Upon completion of the checklist for at least one year, the CEO or designee shall audit the completed checklist and review the intake process to ensure all individuals have physical examinations completed timely with all required information. Documentation of audits shall be kept. (DPOC by AES,HSLS on 6/27/19)] 06/14/2019 Implemented
6400.186(b)Individual #1's ISP review for the review period 01/19/19 through 04/20/19 was not dated by the program specialist.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The program Specialist reviewed and signed/dated the Quarterly Review for the individual. The Quarterly review form has been updated with a signature/date space for the Program Specialist and the individual. The new Quarterly Review format has been used within the past few months for ISP reviews. There has been no issues reported by the individuals Support Coordinator or Administrative Entities. The Program Specialist will review the individuals file to verify signatures and dates, when preparing for the six (6) month ISP review team meeting that is initiated by the Program Specialist. 06/14/2019 Implemented
SIN-00178811 Renewal 10/27/2020 Compliant - Finalized