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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.52(a)(1) | Direct Service Worker #1 completed 9 hours of training related to job skills and knowledge during the 2023 annual training year, dated 1/1/23 through 12/31/23. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director:
1. 6400.52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year:
¿ Direct service workers,
¿ Direct supervisors of direct service workers; and
¿ Program specialists.
2. 6400.52(b)(1-5) ¿ 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.
¿ 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 Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations.
¿ Individual rights.
¿ Recognizing and reporting incidents.
¿ The safe and appropriate use of behavior supports if the person works directly with an individual
3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. |
02/05/2024
| Implemented |
| 6400.52(c)(1) | Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | 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. | On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director:
1. 6400.52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year:
¿ Direct service workers,
¿ Direct supervisors of direct service workers; and
¿ Program specialists.
2. 6400.52(b)(1-5) ¿ 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.
¿ 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 Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations.
¿ Individual rights.
¿ Recognizing and reporting incidents.
¿ The safe and appropriate use of behavior supports if the person works directly with an individual
3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. |
02/05/2024
| Implemented |
| 6400.52(c)(2) | Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: 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. | 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. | On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director:
1. 6400.52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year:
¿ Direct service workers,
¿ Direct supervisors of direct service workers; and
¿ Program specialists.
2. 6400.52(b)(1-5) ¿ 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.
¿ 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 Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations.
¿ Individual rights.
¿ Recognizing and reporting incidents.
¿ The safe and appropriate use of behavior supports if the person works directly with an individual
3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. |
02/05/2024
| Implemented |
| 6400.52(c)(3) | Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director:
1. 6400.52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year:
¿ Direct service workers,
¿ Direct supervisors of direct service workers; and
¿ Program specialists.
2. 6400.52(b)(1-5) ¿ 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.
¿ 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 Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations.
¿ Individual rights.
¿ Recognizing and reporting incidents.
¿ The safe and appropriate use of behavior supports if the person works directly with an individual
3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. |
02/05/2024
| Implemented |
| 6400.52(c)(4) | Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director:
1. 6400.52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year:
¿ Direct service workers,
¿ Direct supervisors of direct service workers; and
¿ Program specialists.
2. 6400.52(b)(1-5) ¿ 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.
¿ 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 Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations.
¿ Individual rights.
¿ Recognizing and reporting incidents.
¿ The safe and appropriate use of behavior supports if the person works directly with an individual
3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. |
02/05/2024
| Implemented |
| 6400.52(c)(5) | Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: the safe and appropriate use of behavior supports. Direct Service Worker #1 works directly with individuals. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director:
1. 52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year:
¿ Direct service workers,
¿ Direct supervisors of direct service workers; and
¿ Program specialists.
2. 6400.52(b)(1-6) ¿ 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.
¿ 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 Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations.
¿ Individual rights.
¿ Recognizing and reporting incidents.
¿ The safe and appropriate use of behavior supports if the person works directly with an individual
¿ Implementation of the individual plan if the person works directly with an individual.
3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. |
02/05/2024
| Implemented |
| 6400.52(c)(6) | Direct Service Worker #1's did not complete the following training topic during the annual training year, dated 1/1/23 through 12/31/23: the implementation of the individual plan. Direct Service Worker #1 works directly with individuals. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | On 2/5/2024, Direct Support Professional was called in the TTSR Administrative Offices and received a retrain on the following regulations from TTSR Assistant Director:
1. 52(a)(1) ¿ The following shall complete 24 hours of training relating to job skills and knowledge each year:
¿ Direct service workers,
¿ Direct supervisors of direct service workers; and
¿ Program specialists.
2. 6400.52(b)(1-6) ¿ 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.
¿ 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 Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable adult protective services regulations.
¿ Individual rights.
¿ Recognizing and reporting incidents.
¿ The safe and appropriate use of behavior supports if the person works directly with an individual
¿ Implementation of the individual plan if the person works directly with an individual.
3. Review of ¿Required 24 Hours of Training For All Staff and Supervisors¿( will be submitted for licensing review). This document is available at all TTSR operated sites and it specifically lists what trainings are mandatory each calendar training year, how many trainings hours are required, how to access the trainings through different apps and websites, and procedures for submission of training certificates and signing off on the annual Training In-Service log document to show proof of completion of trainings. |
02/05/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 received fire safety training 1/10/20 and then again 1/2022. | 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. | 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 |
| 6400.166(a)(11) | Individual #1's March 2022 medication administration record did not include the diagnosis or purpose for each medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | A review of 55PA Code Chapter 6400.166(a)(11)took place with TTSR Administrator and Residential Coordinator who met with TTSR Assistant Director and TTSR Compliance Officer. This meeting took place on 3/31/2022 and the review consisted of the following:
¿ Violation found during licensing inspection in which the MARS for identified individuals did not contain the diagnosis or purpose of medications prescribed by a physician on the MAR for staff knowledge.
¿ Need for all MARS agency-wide to include the diagnosis and purpose for all medications prescribed by a physician to include pro re nata medications
Compliance will be measured during routine monthly reviews and checks of all MARS received from the pharmacy to ensure that all MARS have all required information including the diagnosis and purpose for all medications prescribed by a physician to include pro re nata medications. TTSR Residential Coordinator states that the pharmacy responsible for the creation of all MARS was informed of the need to reflect diagnosis and purpose of all prescribed medications on the MARS on 3/29/2022. On 3/30/2022, TTSR also received the MARS for April 2022 but Residential Coordinator has hand written all diagnosis and purposes on the MARS (hand written) and this will ensure that all staff are aware of the purpose of each medication for the month until the pharmacy makes the needed additions starting in May of 2022. Attached is a copy of the MAR for individual #1 which shows that the MAR which will be used to track medications administered shows the diagnosis or purpose of each medication for the individual for the month of April 2022. Also attached is the sign off sheet that shows that the Residential Coordinator was retrained on 55PA Code Chapter 6400.166(a)(11) and that the pharmacy who creates the MARS for individuals at TTSR will show diagnosis and purpose of all medications for every TTSR individual. |
03/29/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(f) | The program specialist provided the assessment dated 1/16/17, for Individual #1, to the SC and plan team members on 1/16/17 for the annual ISP meeting on 2/7/17. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| On 1/19/2018, a meeting/ review of 55 PA Code Chapter 6400.181(f) took place. During annual licensing inspection it was learned that there was an instance in which protocol for delivery of assessment from provider to SC was not followed. The violation was as follows:
- 55 PA Code Chapter 6400.181(f)- The program specialist provided the assessment dated 1/16/17, for Individual #1, to the SC and plan team members on 1/16/17 for the annual ISP meeting on 2/7/17.
During the 1/19/2018 review with Program Specialist (who oversees the caseload of the individual where violation was found) and TTSR Compliance Officer, Tom acknowledges that he did in fact fail to provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
By signing attached document, Tom acknowledges that he has been retrained on 55 PA Code Chapter 6400.181 (f). Tom will ensure that his SC will receive the assessment at least 30 days prior to ISP meeting for any development, annual update, and revisions.
[Immediately, the CEO or designated management staff person shall develop and implement a tracking system to ensure the program specialist provides all individuals assessment to all plan team members at least 30 calendar days prior to the ISP meeting to include documentation of the correspondence. At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of correspondence documentation and the aforementioned tracking system to ensure the program specialist(s) provides all individuals' assessments to all plan team members at least 30 calendar days prior to the ISP meeting. Documentation of audits shall be kept. (AS 1/26/18)] |
01/19/2018
| Implemented |
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