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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | Individual #1's bedroom does not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | On 1/6/2017, a mirror was placed on Individual #1¿s wall. House supervisor will be tasked with making sure that a mirror remains on the walls of the individuals who reside at this site to remain in compliance with regulation 6400.81(k)(6). During a meeting with house supervisor held on 1/6/2017, a review of regulation 6400.81(k)(6) took place and she acknowledges (by signing the attached meeting signature page) that she will ensure that there are mirrors in all bedrooms at all times through routine bedroom inspections. TTSR Administrative staff will conduct random and routine house inspections throughout the year to see that all 6400 regulations are met in the home. In the event that an individual wishes to not have a mirror in their bedroom, TTSR will apply for a waiver to request that a mirror not be placed in the bedroom. Until such time as a waiver is obtained, the mirror will remain in the individual¿s bedroom.[Immediately and at least quarterly, a designated staff person shall check all individuals' bedrooms to ensure each individual has a mirror as required. House supervisor shall educate all staff persons working in community homes that each individual shall have a mirror in their bedroom and to monitor throughout the course of their duties. (AS 2/7/17)] |
01/06/2017
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's license expired on January 6, 2014. The self- inspection was completed on 4/30/13 which is more than 6 months prior to the license expiration date. Repeat Violation 10/16/12, et al. | (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.
| On 1/30/2014, Training Toward Self Reliance, Inc. CEO as well as the Assistant Director for TTSR met at approx. 10:00AM to discuss the findings of the Licensing Inspection that was held on January 7th, 2014 through January 9th, 2014. One of the areas of non-compliance for all TTSR sites reads, ¿The home's license expired on January 6, 2014. The self- inspection was completed on 4/30/13 which is more than 6 months prior to the license expiration date.¿ During this meeting between the CEO and Assistant Director, it was agreed upon that after review of the regulations associated with this area of non-compliance that the Assistant Director as well as the CEO will be solely responsible for not only the inspection of all TTSR sites agency-wide, but also will ensure that the Licensing Score sheets are completed in the time frame designated by PA Code Chapter 6400.15 (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.) To ensure that the assessments are completed in the time allotted, TTSR CEO as well as Assistant Director will complete the above mentioned tasks during the months of September and October 2014 (which is within the 3 to 6 month timeframe allotted for completion of this task as our License will be set to expire in January of 2015). TTSR CEO will maintain these Score sheets for submission during the next State Licensing Inspection in 2015. Attached in binder is a signed document which shows that the meeting took place on 1/30/2014. |
01/30/2014
| Implemented |
| 6400.44(b)(2) | 44 b) (1-19) The Program Specialist shall be responsible for the following:
The job description for the program specialist did not include the following functions and duties: Coordinating and completing the assessments, providing the assessment as required under 6400.181(f) (relating to the assessment), participating in the development of the ISP, ISP annual update and ISP revision, and reviewing the ISP, annual updates and revisions under 6400.186 for content accuracy.
| (b) The program specialist shall be responsible for the following: (2) Providing the assessment as required under § 6400.181(f) (relating to assessment).
| Changes were made to the Job Description for all program Specialists on 1/10/2014. Attached is a copy of the revised job description (in binder). Also attached is a sign off sheet for a meeting with all program specialists who were trained on the additions made to this policy on 1/10/2014. The attached training verification sheet was signed by all program specialists acknowledging that they understand that they are responsible for additions made to their job description to include; coordinating and completing the assessments, providing the assessments as required under 6400.181 (f)(relating to assessment), participating in the development of the ISP, ISP annual update, and ISP revision, and reviewing the ISP, annual updates, and revisions under 6400.186 for content accuracy. The Assistant Director for TTSR was responsible for the update to this policy. The Assistant Director also coordinated the meeting to review above mentioned changes. |
01/10/2014
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
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