| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill conducted 12/19/21 did not include the 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. | A retrain was held on 4/1/2022 for all supervisors who had areas of non-compliance during the licensing inspection as it pertains to fire drills and PA Code Chapter 6400.112(c). A full retrain of all areas of need for each fire drill (to include 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, review of the revised fire drill process as well as a review of the revised fire drill checklist ) was conducted in which these identified supervisors were retaught all regulations regarding fire safety. Attached is a copy of the sign off sheet which indicates that this retrain took place and that all site supervisors acknowledge that they are aware and will be responsible for initial review of all fire drills before submission to the Administrative office for second review. If areas of the fire drill are found during initial review, supervisor will ensure that feedback is given to the staff and another fire drill will be conducted during that shift with those same staff until the fire drill and all documentation is completed as needed and is compliant with Pa 55 Code standards. |
04/01/2022
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #2's physical examination completed 9/3/21 did not include Tuberculin skin testing by Mantoux method with negative results. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | During a meeting/ review of 55 PA Code Chapter 6400.151(c)(2), (c)(3), and (c)(4) with TTSR Human Resource Department held on 4/1/2022, all participating parties reviewed this violation and acknowledge that they are aware that all physicals received for newly hired as well as veteran staff (every two years) will include a signed statement that the employee is free of serious communicable diseases, received and had a TB Test with results verified by a medical professional (RN, LPN, PAC, or Physician), and that the employees in good general health and can perform work-related duties without exception and has no condition which might interfere with the health of the individuals within the home.
Attached is a copy of the physical that Staff#2 was asked to have redone to ensure that all regulations are met and the TTSR Physical form was filled out completely as needed for compliance.Also attached is a signature page that shows that HR Coordinator was retrained on 55 PA Code Chapter 6400.151(c)(2), (c)(3), and (c)(4) |
04/04/2022
| Implemented |
| 6400.151(c)(3) | Direct Service Worker #2's physical examination completed 9/03/2021 did not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | During a meeting/ review of 55 PA Code Chapter 6400.151(c)(2), (c)(3), and (c)(4) with TTSR Human Resource Department held on 4/1/2022, all participating parties reviewed this violation and acknowledge that they are aware that all physicals received for newly hired as well as veteran staff (every two years) will include a signed statement that the employee is free of serious communicable diseases, received and had a TB Test with results verified by a medical professional (RN, LPN, PAC, or Physician), and that the employees in good general health and can perform work-related duties without exception and has no condition which might interfere with the health of the individuals within the home.
Attached is a copy of the physical that Staff#2 was asked to have redone to ensure that all regulations are met and the TTSR Physical form was filled out completely as needed for compliance.Also attached is a signature page that shows that HR Coordinator was retrained on 55 PA Code Chapter 6400.151(c)(2), (c)(3), and (c)(4) |
04/04/2022
| Implemented |
| 6400.151(c)(4) | Direct Service Worker #2's physical examination completed 9/3/21 did not include information of medical problems which might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | During a meeting/ review of 55 PA Code Chapter 6400.151(c)(2), (c)(3), and (c)(4) with TTSR Human Resource Department held on 4/1/2022, all participating parties reviewed this violation and acknowledge that they are aware that all physicals received for newly hired as well as veteran staff (every two years) will include a signed statement that the employee is free of serious communicable diseases, received and had a TB Test with results verified by a medical professional (RN, LPN, PAC, or Physician), and that the employees in good general health and can perform work-related duties without exception and has no condition which might interfere with the health of the individuals within the home.
Attached is a copy of the physical that Staff#2 was asked to have redone to ensure that all regulations are met and the TTSR Physical form was filled out completely as needed for compliance.Also attached is a signature page that shows that HR Coordinator was retrained on 55 PA Code Chapter 6400.151(c)(2), (c)(3), and (c)(4) |
04/04/2022
| Implemented |
| 6400.46(b) | Direct Service Worker #2, #3 and #4 were not provided annual training in fire safety during training year 1/1/21 through 12/31/21. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | TTSR was unable to conduct its annual fire safety training for all staff and individuals within the agency during January of 2021. The reason for not being able to offer this training was due to the COVID-19 pandemic and state and local regulations prohibiting gathering s of people over a certain number as well as the uncertainty and severity of the virus and pandemic itself. Also during this time when TTSR normally has its annual fire safety training for all staff and individuals, Clarion County was experiencing high numbers of confirmed COVID cases throughout the area. It was deemed necessary to cancel the scheduled trainings in order to keep both the individuals and staff safe from the virus and pandemic. At the time the decision was made to cancel the annual fire safety training, TTSR was unaware that there were oversight approved videos that could be watched in lieu of a formal face to face training as TTSR is accustomed to doing. TTSR was successfully able to complete and offer the annual fire safety which took place on January 10th and 11th , 2022 and we, as an agency, are compliant until January of 2023. In the event that TTSR is unable to, in the future, conduct mandatory trainings in order to compliance in whatever area is needed, TTSR is looking to purchase Fire Safety videos that are ODP approved and meet the requirements for for compliance as it relates to 55 PA Code Chapter 6400.113(a). TTSR has already purchased fire safety videos called ¿Fire Safety Training, Training For Anyone Including Individuals With Developmental Disabilities And For Persons Providing Them Services¿. These videos are distributed by Program Development Associates (www.Disability Training.com) and will be maintained at each site and will be used in the event that TTSR can not conduct our Annual Fire Safety Training face to face and in large numbers. TTSR is also looking into a company named Reliant to research what offerings they have in the event that we can not offer Fire Safety training in-person and need to seek approved fire safety trainings on-line for both staff and individuals. Lastly, TTSR is looking into videos called, ¿Get Out Alive¿ which we were told were ODp approved videos that meet requirements for fire safety training for both individuals and staff. |
04/01/2022
| Implemented |
| 6400.52(c)(1) | Chief Executive Officer #1, Direct Service Workers #2, #3 and #4 were not provided annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during training year 1/1/21 through 12/31/2021. | 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. | TTSR was unable to conduct its annual mandated trainings for all staff and individuals within the agency during January of 2021 through December 2021. The reason for not being able to offer this training was due to the COVID-19 pandemic and state and local regulations prohibiting gathering s of people over a certain number as well as the uncertainty and severity of the virus and pandemic itself. Also during this time when TTSR normally has its annual trainings (Early January)and during the time that TTSR offers mandatory Fire Safety Training for all staff and individuals, Clarion County was experiencing high numbers of confirmed COVID cases throughout the area. It was deemed necessary to cancel the scheduled trainings in January of 2021 in order to keep both the individuals and staff safe from the virus and pandemic.
TTSR was successfully able to complete and offer the annual fire safety to include mandatory trainings for all staff and individuals which took place on January 10th and 11th , 2022 and we, as an agency, are compliant until January of 2023. The following were trained to all staff and individuals during these January 10th and 11th, 2022 training sessions:
¿ Application of Person Centered Practices 6400.52(c)(1)
¿ Community Integration 6400.52 (c)(1)
¿ Individual Choice6400.52 (c)(1)
¿ Supporting Individuals to develop and maintain relationships 6400.52 (c)(1)
¿ Prevention/ Detection of Abuse 6400.52 (c)(2)
¿ Detection and Reporting Abuse 6400.52 (c)(2)
¿ Individual Rights 6400.52 (c)(3)
¿ Recognizing/ Reporting Incidents 6400.52 (c)(4)
¿ Use Of Behavioral Supports 6400.52 (c)(5)
¿ Implementation of the Individuals¿ Plan 6400.52 (c)(6) |
04/01/2022
| Implemented |
| 6400.52(c)(2) | Chief Executive Officer #1, Direct Service Workers #2, #3 and #4 were not provided annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during training year 1/1/21 through 12/31/2021. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: 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 services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | TTSR was unable to conduct its annual mandated trainings for all staff and individuals within the agency during January of 2021 through December 2021. The reason for not being able to offer this training was due to the COVID-19 pandemic and state and local regulations prohibiting gathering s of people over a certain number as well as the uncertainty and severity of the virus and pandemic itself. Also during this time when TTSR normally has its annual trainings (Early January)and during the time that TTSR offers mandatory Fire Safety Training for all staff and individuals, Clarion County was experiencing high numbers of confirmed COVID cases throughout the area. It was deemed necessary to cancel the scheduled trainings in January of 2021 in order to keep both the individuals and staff safe from the virus and pandemic.
TTSR was successfully able to complete and offer the annual fire safety to include mandatory trainings for all staff and individuals which took place on January 10th and 11th , 2022 and we, as an agency, are compliant until January of 2023. The following were trained to all staff and individuals during these January 10th and 11th, 2022 training sessions:
¿ Application of Person Centered Practices 6400.52(c)(1)
¿ Community Integration 6400.52 (c)(1)
¿ Individual Choice6400.52 (c)(1)
¿ Supporting Individuals to develop and maintain relationships 6400.52 (c)(1)
¿ Prevention/ Detection of Abuse 6400.52 (c)(2)
¿ Detection and Reporting Abuse 6400.52 (c)(2)
¿ Individual Rights 6400.52 (c)(3)
¿ Recognizing/ Reporting Incidents 6400.52 (c)(4)
¿ Use Of Behavioral Supports 6400.52 (c)(5)
¿ Implementation of the Individuals¿ Plan 6400.52 (c)(6) |
04/01/2022
| Implemented |
| 6400.52(c)(3) | Chief Executive Officer #1, Direct Service Workers #2, #3 and #4 were not provided annual training in Individual rights during training year 1/1/21 through 12/31/2021. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | TTSR was unable to conduct its annual mandated trainings for all staff and individuals within the agency during January of 2021 through December 2021. The reason for not being able to offer this training was due to the COVID-19 pandemic and state and local regulations prohibiting gathering s of people over a certain number as well as the uncertainty and severity of the virus and pandemic itself. Also during this time when TTSR normally has its annual trainings (Early January)and during the time that TTSR offers mandatory Fire Safety Training for all staff and individuals, Clarion County was experiencing high numbers of confirmed COVID cases throughout the area. It was deemed necessary to cancel the scheduled trainings in January of 2021 in order to keep both the individuals and staff safe from the virus and pandemic.
TTSR was successfully able to complete and offer the annual fire safety to include mandatory trainings for all staff and individuals which took place on January 10th and 11th , 2022 and we, as an agency, are compliant until January of 2023. The following were trained to all staff and individuals during these January 10th and 11th, 2022 training sessions:
¿ Application of Person Centered Practices 6400.52(c)(1)
¿ Community Integration 6400.52 (c)(1)
¿ Individual Choice6400.52 (c)(1)
¿ Supporting Individuals to develop and maintain relationships 6400.52 (c)(1)
¿ Prevention/ Detection of Abuse 6400.52 (c)(2)
¿ Detection and Reporting Abuse 6400.52 (c)(2)
¿ Individual Rights 6400.52 (c)(3)
¿ Recognizing/ Reporting Incidents 6400.52 (c)(4)
¿ Use Of Behavioral Supports 6400.52 (c)(5)
¿ Implementation of the Individuals¿ Plan 6400.52 (c)(6) |
04/01/2022
| Implemented |
| 6400.52(c)(4) | Chief Executive Officer #1, Direct Service Workers #2, #3 and #4 were not provided annual training in recognizing and reporting incidents during training year 1/1/21 through 12/31/2021. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | TTSR was unable to conduct its annual mandated trainings for all staff and individuals within the agency during January of 2021 through December 2021. The reason for not being able to offer this training was due to the COVID-19 pandemic and state and local regulations prohibiting gathering s of people over a certain number as well as the uncertainty and severity of the virus and pandemic itself. Also during this time when TTSR normally has its annual trainings (Early January)and during the time that TTSR offers mandatory Fire Safety Training for all staff and individuals, Clarion County was experiencing high numbers of confirmed COVID cases throughout the area. It was deemed necessary to cancel the scheduled trainings in January of 2021 in order to keep both the individuals and staff safe from the virus and pandemic.
TTSR was successfully able to complete and offer the annual fire safety to include mandatory trainings for all staff and individuals which took place on January 10th and 11th , 2022 and we, as an agency, are compliant until January of 2023. The following were trained to all staff and individuals during these January 10th and 11th, 2022 training sessions:
¿ Application of Person Centered Practices 6400.52(c)(1)
¿ Community Integration 6400.52 (c)(1)
¿ Individual Choice6400.52 (c)(1)
¿ Supporting Individuals to develop and maintain relationships 6400.52 (c)(1)
¿ Prevention/ Detection of Abuse 6400.52 (c)(2)
¿ Detection and Reporting Abuse 6400.52 (c)(2)
¿ Individual Rights 6400.52 (c)(3)
¿ Recognizing/ Reporting Incidents 6400.52 (c)(4)
¿ Use Of Behavioral Supports 6400.52 (c)(5)
¿ Implementation of the Individuals¿ Plan 6400.52 (c)(6) |
04/01/2022
| Implemented |