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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 10/29/25, at 11:15 AM, the non-slip mat of the tub located in the full bathroom on the home's main level was discolored in several areas with brownish stains and contained 13 black, circular spots appearing to be mold and/or mildew. At 11:31 AM, the interior of the refrigerator and freezer unit located in the home's detached garage, which contained various food items, such as packaged American cheese, frozen beef patties, a 12-can pack of Diet Mountain Dew, a one-gallon jug of iced tea, a drink pitcher filled with what appeared to be red Kool-Aid or juice, a half-gallon container of chocolate milk, etc., was lined throughout with several black and brown stains of debris and food particles. | Clean and sanitary conditions shall be maintained in the home. | During licensing inspection, it was found that the bath mat located in the bathroom of the residence at was discolored and moldy. Site Supervisor removed the bathmat immediately upon discovery and replaced the bathmat with a newly purchased on 10/30/2025. Attached is a photo of the bathtub and the clean and sanitary bathmat placed 10/30/2025.
A review of regulation 64(a) took place on 10/31/2025. The topic of discussion was the importance of maintaining cleanliness in all areas of the home. It was discussed that the reason for this regulation was cited was due to the moldy appearance of the bathmat. A discussion was had on the importance of minimizing the risk of illness, infection, or injury and provide for a dignified living environment.
During licensing inspection, it was found that the refrigerator located in the detached garage of the residence at 31 Summerville Road, Rimersburg, PA, was unfit to contain any food items, dirty and moldy. This refrigerator is inoperable and served no purpose in the home. TTSR Maintenance crew removed the refrigerator from the garage and disposed of it off of TTSR grounds. Attached is a photo of the area of the garage where the refrigerator was removed from and disposed of.
A review of regulation 64(a) took place on 10/31/2025. The topic of discussion was the importance of maintaining cleanliness in all areas of the home. It was discussed that the reason for this regulation was cited was due to the moldy and unhealthy appearance of the refrigerator. A discussion was had on the importance of minimizing the risk of illness, infection, or injury and provide for a dignified living environment.
Compliance will be assessed through routine monthly inspections by site staff, site supervisor, as well as TTSR Administrative staff and Maintenance (unannounced site inspections).
By signing attached document, all parties acknowledge the importance of cleanliness as it pertains to regulation 64(a), and will ensure that all areas of the home are free from any health risks and hazardous conditions.
By signing attached document, all parties acknowledge the importance of cleanliness as it pertains to regulation 64(a), and will ensure that all areas of the home are free from any health risks and hazardous conditions. |
10/30/2025
| Implemented |
| 6400.72(a) | On 10/29/25, at 11:08 AM, the window facing the home's right side located in the dining room did not have a screen. At 11:09 AM, the second window furthest from the entry door located in the home's living room did not have a screen. At 11:11 AM, the only window in Individual #1's bedroom did not have a screen. At 11:20 AM, the window adjacent to the entry door of Individual #2's bedroom did not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | At time of licensing inspection, the screens in the dining area, common living area, Individual#1's bedroom, and Individual #2's bedroom windows were found to not be placed in the windows. Although the screens were on site in the garage, they were not positioned in the windows as required. TTSR Head of Maintenance inserted the screens into the windows on 10/29/2025. Attached to POC are photos of the screens in the windows and the photos were taken on 10/29/2025.
Compliance will be assessed through routine quarterly inspections by site staff, site supervisor, as well as TTSR Administrative staff (unannounced site inspections) and TTSR will continue to ensure that these windows remain with screens at all times.
A retrain on regulation 72(a) took place on 10/30/2025. During this retrain, site supervisor as well as TTSR Maintenance Head reviewed regulation and acknowledge that compliance will be assured through random quarterly site inspections and that all windows shall be securely screened at all times throughout the year. |
10/30/2025
| Implemented |
| 6400.72(b) | On 10/29/25, at 11:11 AM, the only window in Individual #1's bedroom was inoperable, as the pane would not remain open in a stationary position and slammed shut in a downward motion. At 11:20 AM on 10/29/25, both windows in Individual #2's bedroom were inoperable, as the panes would not remain open in a stationary position and slammed shut in a downward motion | Screens, windows and doors shall be in good repair. | During licensing inspection of the home located at it was found that one window in each of the two Individuals' bedrooms would not stay open and would close upon release of the window. Because of this, the two windows are deemed to not be in good repair.
On 10/30/2025, TTSR Maintenance Head arrived at the site and hooked spring tensioners into the window frame which now holds the window open upon release. Videos are available of both windows at TTSR and could not be saved for submission to ODP Review. Videos available upon request via text.
A review of regulation 72(b) took place on 10/31/2025. The topic of discussion was the need for all windows, doors, and screens to be in good repair. Site Supervisor was reminded to check all windows to ensure that they can remain open for ventilation in the bedrooms and if open that screens are in place as needed for compliance. Compliance will be ensured by routine site inspections and monthly walkthroughs by both Site Supervisor as well as TTSR Administration and Maintenance department.
By signing below, all parties acknowledged that they were retrained on regulation 72(b) and will ensure that all windows, doors, and screens are operable and in good repair at all times. |
10/30/2025
| Implemented |
| 6400.81(h) | Individual #2's current restrictive procedure plan, dated 12/13/24, their current assessment, completed on 9/15/25, and their Service Plan, last updated 9/9/25, contained no reference to or language regarding the limitation of an outside view in Individual #2 bedroom. However, on 10/29/25, at 11:20 AM, both windows in Individual #2's were covered entirely with a frosted adhesive covering, preventing a view of the outside. | Each bedroom shall have at least one exterior window that permits a view of the outside. | During licensing inspection on 10/29/2025, it was found that individual #1 had window tint over his one window. This tint did allow for Individual #1 to have full sight of the outside area.
On 10/29/2025, TTSR Maintenance employee went to the site and ripped off the window tint from the one window in the bedroom entirely. Attached are photos (from 10/29/2025) of the window. Image #1 shows the interior of the window after the tint was removed from the window and you can clearly see the back yard.
A review of regulation 81(h) took place on 10/30/2025 with Site Supervisor as well as TTSR Maintenance worker. Both reviewed the regulation and acknowledge that they will ensure that no window has tint that prevents a view of the outdoors in the future. Compliance will be ensured by routine site inspections and monthly walkthroughs by both Site Supervisor as well as TTSR Administration and Maintenance department. |
10/30/2025
| Implemented |
| 6400.163(d) | On 10/29/25, at 11:00 AM, unlocked and accessible in the home's first aid kit, were 12 packets of Non-Aspirin (Acetaminophen), each containing two 325 mg tablets. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | During licensing inspection, it was found that 12 packets of acetaminophen were found in the first aid kit which was not double locked as all medications should be. The packets were removed by TTSR Administrator at the time of the inspection and were later placed in the locked medication cabinet in the staff room and then the room was secured and locked by staff ensuring compliance (10/29/2025).
A training/ discussion took place on 10/30/2025 in which Site Supervisor was retrained on regulation 163(d)- medication not locked appropriately double locked in staff office. During this retrain, Site supervisor was retrained on the need for locking medications and ensuring that all medication remain in their original container regardless of whether or not the medication is an over- the-counter medication or prescribed. Attached is a signature page acknowledging that site supervisor received a retrain on the above mentioned regulations and she agrees to adhere to the regulations to ensure compliance moving forward. |
10/30/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The vent in the bathroom had an accumulation of dirt. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 11/18/2014, House supervisor Lori Dick met with TTSR Assistant Director to talk about the amount of dust and dirt found on the vent in the bathroom found in the bathroom of the home during licensing inspection. Lori tells me that the vent was cleaned and disinfected as of 11/5/2014 and states that the vent remains clean and operable presently (see attached pictures of photos taken on 11/17/2014). Lori also signed the attached document stating that she and Assistant director met to discuss the issues and that Lori will routinely check all surfaces, ceilings, and walls of the home on a regular basis to ensure that all are free from dust and dirt. TTSR Administrative staff will oversee this by conducting unannounced site inspections of the home to ensure that this site remains in compliance as far as cleanliness inside and outside of the home. A house supervisor meeting also took place on 11/20/2014 to discuss areas of non-compliance found in the homes during licensing inspection. A signature page accompanies the topics of discussion for this meeting to show that areas of non-compliance were addressed and to ensure that all houses are aware of these issues and to make sure that their homes do not allow these areas of non-compliance to occur in their homes. |
11/18/2014
| Implemented |
| 6400.112(c) | The fire drill records from October, 2013 to October, 2014 do not indicate problems encountered. | 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. | On 11/6/2014, TTSR Secretary (Denise Babcock) met with Assistant Director, Matthew Gladin to discuss an area of non-compliance found during licensing inspection. The topic of discussion was the need for change on TTSR¿s ¿Fire System Check/ Fire Drill Report¿. Additions were made to the attached form which allows the staff responsible for conducting the fire drill to document ¿Problems encountered during the fire drill¿. If on the report, staff specify that there were problems encountered during the fire drill, staff are to document in detail what the problem was and how they will attempt to remedy the problem during future drills. Denise Babcock will be responsible for ensuring that on each fire drill received on a monthly basis, that the staff responsible for conducting the fire drills is successfully completing this section of the report to ensure follow up by appropriate TTSR Administrator. Changes were made to the Fire drill form on 11/4/2014 and was trained to Denise Babcock on 11/6/2014. Denise will talk to each house supervisor for each site to ensure that all are aware of these changes made to the form and to ensure that appropriate follow up occurs in the event that problems occurred during any fire drill. At a supervisor meeting held on 11/20/2014, all house supervisors were given the new form for fire drills and were given an explanation of the changes made to the fire drill form and how to properly ensure that the fire drill form should be completed in its entirety (signature page attached) |
11/06/2014
| Implemented |
| 6400.114(b) | A container to discard smoking materials is provided in the designated smoking area; however, over 50 cigarettes butts were observed discarded throughout the gravel driveway. | Written smoking safety procedures shall be followed. | On 11/18/2014, House supervisor Lori Dick met with TTSR Assistant Director to talk about the abundance of cigarette butts found in the driveway during licensing inspection. Lori tells me that the cigarette butts were all cleaned up as of 11/5/2014 and states that the cigarette butts remain in the receptacle located outside of the home and not in the driveway (see attached pictures of photos taken on 11/17/2014). Lori also signed the attached document stating that she and Assistant director met to discuss the issues and that Lori will routinely check her driveway for discarded cigarette butts and will ensure that she or other staff will pick up any found on the premises on a regular basis. TTSR Administrative staff will oversee this by conducting unannounced site inspections of the home to ensure that this site remains in compliance as far as cleanliness inside and outside of the home. A house supervisor meeting also took place on 11/20/2014 to discuss areas of non-compliance found in the homes during licensing inspection. A signature page accompanies the topics of discussion for this meeting to show that areas of non-compliance were addressed and to ensure that all houses are aware of these issues and to make sure that their homes do not allow these areas of non-compliance to occur in their homes. |
11/18/2014
| Implemented |
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