| 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 |
| 6400.67(a) | On 10/16/12, the two-door cabinet in the main floor bathroom had a missing door. (Fully implemented 4/11/2013 CEM) | (a) Floors, walls, ceilings and other surfaces shall be in good repair.
| On 10/18/2012, the cabinet was transformed into a shelf (see attched). 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 3/18/2013 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. due to a house fire on 2/18/2013 and the damage sustained in the fire, TTSR will not be able to montior this home for a considerable amount of time (6 to 7 months at least). as evidenced by trainings listed above, all superivosory staff were trained and will maintain the compliance standards at the future homes.
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03/11/2013
| Implemented |
| 6400.104 | On 10/15/12, there was no documentation to indicate that the local fire department was notified in writing of the exact location of Individual #1's bedroom. Individual #1's admission date is 8/7/12. (Fully implemented 4/11/2013 CEM) | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Attached is a copy of the letter sent to the Knox Borough Fire Depratment, addressed to the Fire Chief that specifically states where TC is as well as other members of the home. The individual's move in date was 8/7/2012 and the letter was sent to the Fire Chief on 8/7/2013. TTSr secretary is responsible for ensuring that this letter is sent to the fire chief in a timely manner (at least day of arrival of individual). House supervisor attended (see attached)regulation training and was informed that not only is a fire drill necessary the day of arrival for any new individual as well as notification must be made to local fire department (as mentioned above) |
03/11/2013
| Implemented |
| 6400.113(a) | On 10/15/12, there was no documentation to indicate that Individual #1 was trained in his responsibilities during fire drills upon initial admission date of 8/17/12. Individual #1 attended an initial fire safety training on 8/17/12. (Fully implemented 4/11/2013 CEM) | (a) An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home.
| as requested by inspector, attached is a copy of the "Incipient Fire Training" which was held on January 2,3,and 4, 2013 as well as a copy of the letter which details the training for January 5, 2012. this document lists the curriculum discussed and was sent by the trainer, michael d. graham from atkinson fire safety inc. TTSR secretary will be responsible for ensuring that this document is maintained by TTSr administration on an annual basis. |
03/11/2013
| Implemented |
| 6400.181(e)(1) | On 10/15/12, the annual assessment for Individual #1, dated 8/22/12, did not include the preferences of the individual. (Fully implemented 4/11/2013 CEM) | (e) The assessment must include the following information:
(1) Functional strengths, needs and preferences of the individual.
| An updated assessment was completed for Individual #1 to reflect his preferences (see attached). Attached is a copy of the curriculum for the assessment training which was held on 11/1/2012. this training was held by the responsible person, josh altman who is the compliance officer for ttsr and will conduct reviews of the assessments with all house supervisors on an annual basis. Highlighted on the attachment is the house supervisor for this site who is responsible for filling out the assessment as well as their signature showing that he/ they attended the training on assessments with the compliance officer on 11/1/2012. The attachment gives specifics on what was discussed throughout the training and in Section 2 Part c shows that the Individual's strengths, needs, and preferences section was trained on and discussed with all house supervisor who are responsible for filling out the assessments for the individuals. |
03/11/2013
| Implemented |
| 6400.195(a) | On 10/15/12, documentation revealed that Individual #1 had been manually restrained once on 9/2/12 and once on 9/16/12 prior to a restrictive procedure plan being written. (Partially implemented-adequate progress 4/11/2013 CEM) | (a) For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| On 10/23/2013, TTSR Program Specialist created a Restrictive Procedure Plan for Individual #1 (see attached). This program Specialist was taught on 10/23/2013 the regulations on the creation of Restrictive Procedures and the regulations associated with by Compliance Officer for TTSR (see attached signature page). Information on individuals coming to live with TTSR will be reviewed by Program Specialists and plans will be developed to ensure their safety in the home and community prior to coming to TTSR. All program specialists for TTSR will receive all incident reports for any incident involving restraint within 72 hours and will create necessary plans to reflect the needs of each individual and to ensure their health, safety, and well-being in the home and community. |
03/11/2013
| Implemented |