Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238687 Renewal 01/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)On 1/31/24, at 1:59PM, two unlabeled plastic spray bottles containing what appeared to be chemical substances were in the cabinet in the laundry room of the home.Poisonous materials shall be stored in their original, labeled containers. It was found during licensing inspection that staff were transferring poisonous cleaning products from a bulk cleaner jug to an unmarked generic spray bottle. On 2/6/2024, TTSR Site Supervisor was called in for a retrain on regulation 62© in which poisonous materials shall be stored in their original labeled containers. House supervisor states that the generic spray bottle was thrown away on 2/5/2024 and that he went and purchased a bottle of the ¿Clorox All Purpose Cleaner¿ on 2/5/2024. 02/06/2024 Implemented
6400.67(b)On 1/31/24, at 1:46 PM, there was a three foot by four foot standing puddle of water on the floor in the corner of the basement of the home and a total of six inches of water along the walls of the basement of the home. Floors, walls, ceilings and other surfaces shall be free of hazards.It was found during licensing inspection that there was a build up of water near or around the furnace area caused by the excessive rain the area received throughout the week prior to licensing inspection. Upon inspection of the basement area of the home, TTSR Maintenance Department noticed a very small crack near the flooring of the basement near the exit door. TTSR Maintenance Department applied RedGard Waterproofing Sealant to the small crack on 2/5/2024. Attached with POC is a picture of the basement taken on 2/6/2024. As shown, there is no water anywhere present on the floor of the basement. 02/05/2024 Implemented
6400.72(b)On 1/31/24, at 1:50 PM, the door in the basement leading outside of the home was stuck and unable to be opened. Screens, windows and doors shall be in good repair. During licensing inspection, the basement door leading to exit of the home was difficult to open. On 1/31/2024, TTSR Head of Maintenance took a hand sander to the upper corner of the door which was getting stuck on the upper corner of the door frame (caused by changing seasons). After the sanding of the corner of the door, the door was easily opened and closed completely with little effort and will be easy for any individual to exit in the event of emergency. Attached to POC is a photo of the door opened and closed completely. 02/06/2024 Implemented
6400.80(b)On 1/31/24, at 1:57 PM, the landing and stairs leading from the basement exit of the home was covered in moss, sticks and leaves. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.During licensing inspection, the landing outside of the basement exit door was extremely cluttered with stick, leaves, and moss which at that time, created a slipping/ tripping hazard for safe egress from the home. On 1/31/2024, Head of Maintenance department cleared the landing of the leaves, moss, and sticks using a shovel to do so. Attached to POC is a photo of the landing taken on 2/6/2024 showing that there are no leaves, moss, or sticks which would impair safe egress from the home at any time. 02/06/2024 Implemented
6400.112(c)The fire drill conducted on 4/16/2023 at 6:00 AM does not include the amount of time it took for evacuation.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. All fire drill reports for all sites will be turned in to TTSR Compliance Officer for review at the end of each month for review to ensure that all fire drill reports are completed as needed and to review if there were any issues encountered during the fire drill process. Follow up and feedback will be given for anything missing on reports or if there were issues during the fire drill. Site supervisor, by signing the attached retrain document, acknowledges that he has been retrained in all areas of the fire drill policies and procedures on 2/2/2024 and will also take a more active role in reviewing all fire drill reports before submitting to Compliance Officer for review. 02/02/2024 Implemented
6400.142(f)Individual #1, date of admission 6/18/2002 has not had a written dental hygiene plan completed.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. TTSR Residential Coordinator revised current Dental Care Contact document to reflect the following changes: - Added ¿How many times a day should this individual brush their teeth?¿ - Added ¿How many times a day should this individual floss their teeth?¿ TTSR Residential Coordinator received a retrain on regulation 142(f) on 2/2/2024 and has signed the attached document stating that she recognizes that all Dental Care Contact documents must contain the above mentioned questions for response by a certified dental professional. Residential Coordinator will then review all submissions of the Dental Care Contact for completion after any Dental appointment is completed and will ensure compliance through monthly reviews of these submissions. 02/02/2024 Implemented
6400.52(c)(5)Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: the safe and appropriate use of behavior supports. Direct Service Worker #1 works directly with individuals.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director: 1. 52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year: ¿ Direct service workers, ¿ Direct supervisors of direct service workers; and ¿ Program specialists. 2. 6400.52(b)(1-6) ¿ The annual training hours specified in subsections (a) and (b) must encompass the following areas: ¿ The application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. ¿ The prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S.§§ 10225.101-10225- 5102), the Child Protective Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations. ¿ Individual rights. ¿ Recognizing and reporting incidents. ¿ The safe and appropriate use of behavior supports if the person works directly with an individual ¿ Implementation of the individual plan if the person works directly with an individual. 3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. 02/05/2024 Implemented
6400.52(c)(6)Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: the implementation of the individual plan. Direct Service Worker #1 works directly with individuals.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director: 1. 52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year: ¿ Direct service workers, ¿ Direct supervisors of direct service workers; and ¿ Program specialists. 2. 6400.52(b)(1-6) ¿ The annual training hours specified in subsections (a) and (b) must encompass the following areas: ¿ The application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. ¿ The prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S.§§ 10225.101-10225- 5102), the Child Protective Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations. ¿ Individual rights. ¿ Recognizing and reporting incidents. ¿ The safe and appropriate use of behavior supports if the person works directly with an individual ¿ Implementation of the individual plan if the person works directly with an individual. 3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. 02/05/2024 Implemented
SIN-00147191 Renewal 12/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment for the home on 10/9/18.The agencies certificate of compliance has an expiration date of 1/6/19.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. TTSR Administrative staff met on 12/18/2018 to discuss the violation and review actions to be taken to prevent the violation from occurring in the future. Those present at the time of this meeting were TTSR CEO, TTSR Assistant Director, and TTSR Compliance Officer. Current procedures for completion were discussed and it was learned that Assistant Director (who was responsible for ensuring completion of the self-assessments for this current licensing inspection) did in fact start the process within the 3 to 6 month timeframe but did not finish them within the timeframe permitted. TTSR checked their Licensing Certificate of Compliance for 2019 (effective 1/6/2019 through 1/6/2020) and will ensure that all self- assessments for all sites are completed within the 3 to 6 month timeframe ( 7/6/2019 to 10/6/2019). TTSR Compliance Officer will receive and review all self-assessments upon completion to ensure that they were completed within the 3 to 6 month timeframe from the expiration of the license. Attached is a signature page showing those in attendance at this meeting participated in the development of the corrective action for this violation. 12/18/2018 Implemented
SIN-00043542 Renewal 10/16/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)On 10/16/12, the agency self-assessment did not include the date the assessment was completed. None of the agency's self-assessments included a date. (Partially implemented-adequate progress 4/11/2013 CEM)(a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. Since Tammy Nelson, CEO, is the person responsible for the completion of each house assessment, she and the Program Manager as well as Compliance Officer for TTSR met on 3/20/2013 to discuss the protocol for completion of assessments. Attached is a copy of the signature sheet as well as the curriculum of topics discussed during this training meeting. In summary, the training involved the completion of the self-inspections as well as a review of the timelines and expectations of the CEO for TTSR in ensuring that the self-assessments for each home are completed thoroughly (INCLUDING ACTUAL DATES WRITTEN ON SCORESHEETS WHICH SHOW THE DATE OF INSPECTION)and in a timely manner (3 to 6 months prior to the expiration date of the agency¿s certificate of compliance). 03/11/2013 Implemented
6400.46(d)On 10/16/12, Staff #1's record indicated that he did not have 24 hours of training relevant to human services annually. Training for staff #1 totalled 19 hours. (Fully implemented 4/11/2013 CEM)(d) Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. The staff that was pulled to have records looked at did in fact have the required 24 hours of in-service training as evidenced by the sign in sheet in the TTSr in-service log (see attached). This page 2 was discovered 2 days following the licensing inspection by TTSr Human Resource Director. HR dIRECTOR WILL CONTINUE TO BE RESPONSIBLE FOR MONITORING THE COMPLETENESS OF THE IN-SERVICE LOG TO ENSURE THAT ALL STAFF WORKING at TTSR have at least the minimum required hours of trainings. 02/18/2013 Implemented
6400.67(a)On 10/16/12, the vanity dresser drawers in the bathroom was peeling paint. On 10/16/12, tile on the bathroom floor next to the vanity dresser were broken. According to agency staff, the damage to the dresser and tile is due to the individual that resides in this home consistently urinating on them. (Fully implemented 4/11/2013 CEM)(a) Floors, walls, ceilings and other surfaces shall be in good repair. Dresser was sanded and repainted on 10/16/2012 (see attached). Tiles were repaired on 10/16/2012 (see attched). On 3/12/2013, trained inspectors who conduct house inspections on a monthly basis using the House Monthly Monitoring Tool inspected this site (see attached monitoring tool). Attached to the Monitoring tool is a sign off sheet for those TTSR administrators who were trained on 3/11/2013 (curriculum attached). Attached is also a sign in sheet and curriculum for a 6400 Regulations/ restrictive procedure policy training which was held on 3/14/2013 which was held for all house supervisors. House supervisors will be responsible for implementing and monitoring of all policies and procedures pertaining to regulations associated with meeting the compliance set forth by 6400 regulations. TTSR administration will serve as oversight as the monthly inspectors to ensure that compliance standards are maintained. 03/11/2013 Implemented
6400.67(b)On 10/16/12, the water-softener tank in the basement area of the home was leaking excessive amounts of water onto the floor. (Fully implemented 4/11/2013 CEM)(b) Floors, walls, ceilings and other surfaces shall be free of hazards.Water tank was repaired on 10/31/2012 (see attached invoice). On 3/12/2013, trained inspectors who conduct house inspections on a monthly basis using the House Monthly Monitoring Tool inspected this site (see attached monitoring tool). Attached to the Monitoring tool is a sign off sheet for those TTSR administrators who were trained on 3/11/2013 (curriculum attached). Attached is also a sign in sheet and curriculum for a 6400 Regulations/ restrictive procedure policy training which was held on 3/14/2013 which was held for all house supervisors. House supervisors will be responsible for implementing and monitoring of all policies and procedures pertaining to regulations associated with meeting the compliance set forth by 6400 regulations. TTSR administration will serve as oversight as the monthly inspectors to ensure that compliance standards are maintained. 03/11/2013 Implemented
6400.186(e)On 10/16/12, records indicated that plan team members were not provided the option to decline Individual #1's 3-month Individual Support Plan documentation, dated 1/3/12. (Partially implemented-adequate progress 4/11/2013 CEM)(e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Attached is a letter that was sent to the legal guardian of individual #1 which requests that the Rights and Releases as well as the Declination Notice be signed by him. As of 2/4/2013, these releases and declination notice have yet to be signed by this parent (as was the case last year). This letter will serve as proof that TTSr continues to attempt to have these documents signed and returned without the follow through from the individual's legal guardian. program Specioalist will continue to request that these documents are returned in a timely manner. 02/18/2013 Implemented
6400.202(d)On 10/17/12, a review of the agency's incident management records revealed that Individual #1 had been placed in four manual restraints on 5/11/12, between 4:20pm and 5:55pm, which exceeded 30 minutes within a 2-hour period. The restraints totalled 45 minutes. (Partially implemented-adequate progress 4/11/2013 CEM)(d) An individual shall be released from the manual restraint within the time specified in the restrictive procedure plan not to exceed 30 minutes within a 2-hour period. 202(d) During a review of 6400 regulations with all house supervisors (sign-in sheet attached as well as a curriculum of what was taught), Compliance Officer for TTSR talked in depth about item 202(d) of the regulations which references violations pertaining to utilization of restraints exceeding 30 minutes in a 2 hour timeframe. TTSR Program Manager spoke and reviewed TTSR¿s Policy and Procedure 7-2-1 which pertains to the agency¿s Restrictive Procedure policies (attached). Program Manager will be responsible for analysis of data pertaining to restraints and will provide feedback to all staff upon receipt of the debriefing documentation. Compliance Officer will oversee the monitoring of incidents in HCSIS. Staff will be provided with de-escalation and positive approach trainings at a date to be determined. Staff are trained to utilize physical interventions when an individual is escalated and displaying behaviors that are a danger to themselves or others. It cannot be assured that staff will not utilize restraints over the 30 minute timeframe in the future, however, by offering these trainings to staff, it is our hopes that staff will adhere to the restrictive procedure policy and will do everything in their power to not only avoid restraints, but also be mindful that they are not to exceed 30 minutes in a 2 hour timeframe. In these trainings, staff will be retrained on healthy and safe alternatives to restraint. These trainings will be made in the near future to include all staff that work at this site. As of 3/14/2013, TTSR has not heard back from Butler HCQU to have these trainings set up. 03/11/2013 Implemented
SIN-00202184 Renewal 03/22/2022 Compliant - Finalized
SIN-00087537 Renewal 12/08/2015 Compliant - Finalized