| 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 |
| 6400.186(b) | Individual #1 did not sign the three month reviews for the following dates: 11-27-13, 2-27-14, 5-27-14 and 8-27-17. | 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.
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11/25/2014
| Implemented |