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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(5) | Individual #1's bedroom does not have a closet or wardrobe. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | On 1/25/2017, TTSR maintenance department visited the site of Individual #1. TTSR maintenance department installed a bar/ clothes rack in Individual¿s bedroom so as to hang shirts and pants if desired. House supervisor will be tasked with making sure that the bar/ rack remains in the bedroom to hang clothes and so that the site remains in compliance with regulation 6400.81(k)(5). During a meeting with house supervisor held on 1/25/2017, a review of regulation 6400.81(k)(5) took place and acknowledges (by signing the attached meeting signature page) that he will ensure that Individual #1 has access to a rack or bar to hang clothing 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. Attached is a photo taken on 1/25/2017 which shows Individual¿s clothes hanging in bedroom.[Immediately and at least quarterly, a designates staff person shall check all community homes to ensure all individuals' bedroom have a closet or wardrobe space with clothing racks and shelves accessible to the individual. (AS 2/7/17)] |
02/03/2017
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom does not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | On 1/9/2017, 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 individual who resides at this site to remain in compliance with regulation 6400.81(k)(6). During a meeting with house supervisor, held on 1/9/2017, a review of regulation 6400.81(k)(6) took place and Knox acknowledges (by signing the attached meeting signature page) that he will ensure that there is a mirror in the bedroom 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. Attached is a photo of a mirror on the wall of Individual #1.[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)] |
01/09/2017
| 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 |
| 6400.67(b) | The bathroom ceiling tile which supported the vent was sagging under the weight and could be in danger of falling from the ceiling. It was sagging from the weight of the ventilation unit. | (b) Floors, walls, ceilings and other surfaces shall be free of hazards. | On 1/13/2014, TTSR Maintenance worker, Russ Colwell arrived at the TTSR operated site located at 2241 Whitmer Road Knox, PA. 16255. The purpose of this visit to the site was to replace ceiling tiles that were found to be loose and falling from the ceiling in the right corner of the room as you enter. Once at the site, Russ Colwell reports that he completed the following tasks:
*Cut out old loose and damaged tiles
*Removed air ventilation system and cleaned it free from dust
*Applied new tiles to the area of the ceiling
*Re-installed air ventilation
*Stapled and glued new tiles up to replace old and worn tiles
Attached is a picture of the ceiling tiles directly above the toilet showing that the old and worn tiles have been replaced as of 1/13/2014.
All surfaces to include, but not be limited to ceilings, walls, floors, and surfaces will be inspected on a bi-monthly basis by TTSR Administrative staff to ensure that all sites meet the requirements set forth in 6400 regulations. Any needed repairs will be done on an as needed basis by TTSR Maintenance department so that all TTSR homes remain in compliance.
By signing attached document, Mr. Colwell attests that he conducted the above mentioned tasks to ensure that the ceiling tiles replaced will meet regulation requirements and are in good repair after replacement on 1/13/2014.
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01/13/2014
| Implemented |
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