Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |