| 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 |