Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00126899 Renewal 12/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. On 12/29/2017, an emergency contact sheet was obtained from the TTSR administrative office and was placed on the back of the telephone used in the common area. House supervisor will be tasked with making sure that emergency contact numbers remain on the phone or near the base of the phone used to make outside calls to remain in compliance with regulation 6400.71. During a meeting with house supervisor, Brooke Clinger held on 1/17/2018, a review of regulation 6400.71 took place and Brooke acknowledges (by signing the attached meeting signature page) that she will ensure that there are emergency contact phone numbers accessible and on the cordless phone itself and near the base of the charging station for the phone at all times through routine house inspections. TTSR Administrative staff will conduct random and routine house inspections throughout the year to see that all 6400 regulations are met in the home. Also attached is a photo of the phone that now has the emergency contact phone numbers attached to the phone. [Immediately and at least monthly, a designated staff person shall do an onsite check of all community homes to ensure telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line and are legible and up-to-date. Documentation of checks shall be kept. (AS 1/26/18)] 12/29/2017 Implemented
SIN-00071330 Renewal 11/05/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The window screen in Individual #1's bedroom has a tear approximately 3 inches by 4 inches in the upper right hand corner. Screens, windows and doors shall be in good repair. The screen window was replaced on 11/5/2014 by TTSR Maintenence department (see attached photo)House supervisors were talked to on 11/20/2014 at a House Supervisors Meeting about the importance of routinely inspecting their homes on a weekly basis and to report any weathered screens for windows or doors to TTSR Administration through the use of the Supervisor Reports documents that identify needs in all homes of TTSR and are turned into the Administrative office on a weekly basis. House supervisors agreed to ensure that all screens are operable and were supportive of TTSR Administration continuing to conduct unannounced bi-monthly inspections of all homes. TTSR maintenance department will also routinely inspect homes when conducting other required and necessary maintenance in the homes to ensure compliance. 11/05/2014 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
6400.112(f)The monthly fire drill conducted from 10-30-13 to 10-12-14 used the front door exit. Alternate exit routes shall be used during fire drills. 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). It was also discussed that staff should switch exit routes from the previous fire drill to ensure that all individuals residing at the home know and can utilize all available escape routes in the home in the event of emergency or fire. 11/20/2014 Implemented
6400.186(b)Individual #1 did not sign the three month review dated 4-28-14.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. On 11/25/2014, TTSR Assistant Director Matthew Gladin met with all TTSR Program Specialists who are in charge of attending all TTSR consumers¿ 3 month reviews of the ISP as well as . The topic of this meeting/ training was to discuss the need for Program Specialists to ensure the following: 1) Individuals will sign and date the ISP Review signature page upon review of the ISP. 2) Program Specialist will sign and date the ISP Review signature page upon review of the ISP. 3) Program Specialists will sign and date the most recent assessment for all individuals. By signing attached signature page, all Program Specialists acknowledge that they received the training on the above mentioned topics and attest that they understand that these 3 steps must be done for all ISP reviews as well as for assessments prior to completion. As oversight, all of TTSR Administration, including Program Specialists will meet on a monthly basis to review any updates to any individual¿s ISP that was reviewed during the prior 30 day timeframe to ensure that all Administrative staff are made aware of important changes and to ensure that the signature pages contain the signatures of both the program Specialist as well as the individual. All assessments will brought to this meeting (if done during the prior month timeframe) to ensure that the assessment contains necessary signatures and dates. 11/25/2014 Implemented
SIN-00043544 Renewal 10/16/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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
6400.202(d)On 10/17/12, the agency's incident management record revealed that Individual #1 and Individual #2 had been manually restrained multiple times which exceeded 30 minutes within a 2-hour period. *On 1/9/12, Individual #1 was restrained 3 times between 8:20pm and 9:30pm totalling 45 minutes. *On 7/9/12, Individual #1 was restrained 4 times between 7:00am and 8:40am totalling 50 minutes. *On 7/9/12, Individual #1 was restrained 3 times between 9:40am and 10:50am totalling 35 minutes. *On 12/19/11, Individual #2 was restrained 3 times between 6:30pm and 8:10pm totalling 45 minutes. *On 3/13/12, Individual #2 was restrained 3 times between 9:20pm and 10:50pm totalling 35 minutes. *On 3/14/12, Individual #2 was restrained 3 times between 9:45am and 11:00am totalling 40 minutes. *On 3/16/12, Individual #2 was restrained 3 times between 8:30am and 10:00am totalling 45 minutes. *On 3/27/12, Individual #2 was restrained 3 times between 4:35pm and 6:15pm totalling 40 minutes. (Partially implemented-adequate progress 4/11/2013 CEM)(d) An individual shall be released from the manual restraint within the time specified in the restrictive procedure plan not to exceed 30 minutes within a 2-hour period. 202(d) During a review of 6400 regulations with all house supervisors (sign-in sheet attached as well as a curriculum of what was taught), Compliance Officer for TTSR talked in depth about item 202(d) of the regulations which references violations pertaining to utilization of restraints exceeding 30 minutes in a 2 hour timeframe. TTSR Program Manager spoke and reviewed TTSR¿s Policy and Procedure 7-2-1 which pertains to the agency¿s Restrictive Procedure policies (attached). Program Manager will be responsible for analysis of data pertaining to restraints and will provide feedback to all staff upon receipt of the debriefing documentation. Compliance Officer will oversee the monitoring of incidents in HCSIS. Staff will be provided with de-escalation and positive approach trainings at a date to be determined. Staff are trained to utilize physical interventions when an individual is escalated and displaying behaviors that are a danger to themselves or others. It cannot be assured that staff will not utilize restraints over the 30 minute timeframe in the future, however, by offering these trainings to staff, it is our hopes that staff will adhere to the restrictive procedure policy and will do everything in their power to not only avoid restraints, but also be mindful that they are not to exceed 30 minutes in a 2 hour timeframe. In these trainings, staff will be retrained on healthy and safe alternatives to restraint. These trainings will be made in the near future to include all staff that work at this site. As of 3/14/2013, TTSR has not heard back from Butler HCQU to have these trainings set up. 03/11/2013 Implemented
SIN-00259124 Renewal 01/22/2025 Compliant - Finalized
SIN-00202186 Renewal 03/22/2022 Compliant - Finalized
SIN-00166531 Renewal 11/13/2019 Compliant - Finalized