Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241853 Renewal 03/28/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Direct Support Staff #1 had their most recent physical examination completed on 10/7/2019.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.During 2380 Annual licensing, it was learned that Staff#1 was not incompliance as it pertains to the required 2 year physicals. The last reported physical on file for this staff was dated 10/7/2019. On 4/3/2024, this staff is scheduled for her physical with her Personal Care Physician. Upon completion of the physical, this staff brought the physical into TTSR Administrative Offices. After dropping off the physical, Staff#1 received a retrain on 55 PA Code Chapter 2380.113(a) in which: ¿ A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. 04/02/2024 Implemented
2380.21(u)Individual #1 was informed of their individual rights and the process to report a rights violation on 2/9/2023 and 2/10/2024.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.During licensing 2380 licensing inspection, it was learned that Individual#1 was informed of their individual rights and the process to report a rights violation on 2/9/2023 and 2/10/2024. A review took place with TTSR Program Specialist on 4/2/2024 in which a retrain of 55 PA Code Chapter 2380.21(u) occurred. This retrain involved the following details: ¿ The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. By signing below, Program Specialist acknowledges the need for the Individual to receive a breakdown of the Individual¿s rights and the process for reporting any violations pertaining to the Individual¿s rights within 365 calendar days from the last review and retrain. Program Specialist will be tasked with ensuring that ALL Individuals under his supervision receive these retrains annually and within 365 days of the previous retrain through monthly checklist reviews for ALL of his current Individuals to ensure that any required needs are met and compliance is maintained. 04/02/2024 Implemented
SIN-00169361 Renewal 01/22/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical examination completed 7/12/18 and then again 8/9/19.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.A meeting/ training was held with TTSR nurse, Residential Coordinator, and House Supervisor and a discussion and review of the consumers¿ physicals took place. It was discussed that at time of annual licensing inspection, Individual#1 residing at the Cranberry House, had a physical completed on 8/9/19. The previous year¿s physical for this consumer was completed on 7/12/2018. A review of 55 PA Code Chapter 2380.111(a) took place and all in attendance acknowledge the importance of ensuring that all physicals for all individuals residing at TTSR will receive their annual physicals within a 12 month timeframe to ensure that regulations are met as it pertains to 55 PA Code Chapter 2380.111(a). TTSR Nurse will be tasked with review of all incoming physicals as of the date of this corrective action to ensure that timeframes are met for all physicals. Residential Coordinator will be tasked with ensuring that all site supervisors are made aware of upcoming medical appointments allowing for sufficient time between notice and the appointment date in the event that there are issues or refusals on the part of the individual on the date of the scheduled appointment. It should be noted that the Site supervisor was made aware of the appointment for this physical a week before the scheduled physical (before the 12 month window for regulations) and did acknowledge that he ¿forgot about it¿. The Site Supervisor did receive disciplinary action (7/28/2019) for failure to ¿ensure client attended primary physician appointment to maintain compliance as per regulations for annual physical and TB testing¿. By signing attached document, all parties acknowledge that they have been retrained on 55 PA Code Chapter 2380.111(a) on 1/27/2020 and will adhere to all responsibilities in the future to achieve compliance.. 01/27/2020 Implemented
SIN-00149204 Renewal 01/31/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Direct Service Worker #1, date of hire 6/5/14, had 16 hours of training for training year 1/1/18 to 12/31/18.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.During 2380 licensing inspection completed on 1/31/2019, it was learned that Direct Service Worker #1, date of hire 6/5/14, had 16 hours of training for training year 1/1/18 to 12/31/18. In response to this area of non-compliance found, TTSR Human resource department has developed a tracking system using Microsoft Excel which will be filled in any time that any staff receives any kind of training pertaining to the Human Services (spreadsheet developed on 2/4/2019 and is attached to this file for review). Quarterly, this tracking system will be reviewed and updated by the Human Resource Assistant and letters notifying all staff will be sent to the respective staff to inform them not only how many training hours they have to date, but also the amount of hours needed to meet compliance for the year (form developed on 2/4/2019 and is attached to this file for review).Once updated and reviewed a quarterly basis by TTSR Human Resource department, this spreadsheet will also be given to TTSR CEO as well as the TTSR Compliance for review to ensure that all program specialists and direct care staff receive their required 24 hours of training hours within the calendar year. 02/04/2019 Implemented
SIN-00128688 Renewal 02/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Direct Service Worker #1 had fire safety training on 1-12-17 and then again on 1-18-18. Direct Service Workers #2 and #3 had fire safety training on 1-12-17 and then again on 1-19-18. Direct Service Worker #4 had fire safety training on 1-13-17 and then again on 1-19-18. Program Specialist #1 had fire safety training on 1-12-17 and then again on 1-19-18.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).During a meeting/ review of 55 PA Code Chapter 2380.36(f) held on 2/21/2018, TTSR CEO met with Compliance officer for TTSR who has been tasked with coordinating all annual fire safety trainings with fire safety expert for all direct care workers as well as all Program Specialists. Compliance Officer was under the impression that fire safety trainings could be held during the month of the previous year¿s training when it should be within the year of the previous year¿s training. After a discussion, it was determined that future fire safety trainings will be coordinated for the month before the expiration of the previous year¿s safety training date (example- If last year¿s training took place in January, TTSR Compliance Officer will coordinate the training in December or before). During this annual training, Program specialists and direct service workers shall be trained by a fire safety expert in the training areas specified in subsection (f). By signing attached document, TTSR Compliance Officer acknowledges that a review of 55 PA Code Chapter 2380.36(f) took place on 2/21/2018 and that he is fully aware that all future trainings must by coordinated and given within a year¿s time of the previous year¿s training. [Within 30 days of receipt of the plan of correction, the CEO and/or compliance officer shall develop and implement a tracking system to ensure timely completion of fire safety training for program specialists and direct service workers. (AS 3/13/18)] 02/21/2018 Implemented
2380.113(c)(3)The communicable disease section was left blank on Direct Service Worker #1's physical examination completed 6-2-17; therefore, compliance could not be measured.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.During a meeting/ review of 55 PA Code Chapter 2380.113(c)(3) with TTSR Human Resource Department held on 2/21/2018, all participating parties reviewed this violation and acknowledge that they are aware that all physicals received for newly hired as well as veteran staff (every two years) will include a signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. To ensure that all future physicals received are completed in their entirety, the protocol for review of physicals has changed. Once a physical is received by TTSR Human Resource Department within timeframe guidelines, it will first be reviewed by TTSR Human Resource Coordinator and a check for completeness will take place. After this review the document will again be reviewed by newly hired Human Resource Assistant (who was hired after the date of this violation- 6/2/2017). After review of document by both parties, and verification of completeness occurs, the document will then be placed and maintained in the direct care worker¿s personnel file. If it is learned that any portion of the received physical document is blank, TTSR Human Resource Department will contact that staff for follow up and to request that they take the document back to their place of examination for completion and to ensure compliance. Any staff with an incomplete physical will not be placed on the working schedule until it is determined that they are free of communicable disease and meet the health requirements for working with any TTSR individual. By signing attached document, all parties agree that they reviewed 55 PA Code Chapter 2380.113(c)(3) and are aware of the protocol for receipt and review of all direct care workers¿ medical documentation to ensure completeness and compliance. [Direct Service Worker #1's physical examination documentation was updated by the medical professional to address communicable disease. Immediately and upon completion, the aforementioned audit process shall be completed for all staff person current physical examinations to ensure all required information is included and there are not any required areas left blank and missing information shall immediately be obtained. Documentation of all audits shall be kept. (AS 3/13/18)] 02/21/2018 Implemented
2380.181(e)(12)Individual #1's assessment, dated 8-25-17 did not included recommendations for specific areas of training, vocational programming and competitive community-integrated employment. This section was left blank.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.During a review with Program Specialist who oversees the caseload of the individual who¿s assessment was reviewed (2/21/2018), program specialist accepted responsibility for leaving this section of the assessment blank. Program Specialist, after a review of PA Code 2380.181 9 ( e ) (12), acknowledges that he will review all assessments from date of these findings and moving forward to ensure completeness of all assessments done for all TTSR consumers. At least quarterly for 1 year, TTSR Compliance Officer will audit a 25% sample of assessments to ensure all required information is included. Documentation of audits shall be kept. Immediately, all Program Specialists shall review all individuals' current assessments to ensure all required information is included. By signing the attached document, Program Specialist and Compliance Officer acknowledge that they reviewed Code 2380. 181 ( e ) (12) during this meeting held on 2/21/2018 and understand the need for completeness of all sections of the assessment for each individual served by the setting and their roles to ensure compliance. [Individual #1's assessment was updated to included recommendations for specific areas of training, vocational programming and competitive community-integrated employment on 3/2/18. Program Specialist(s) have reviewed all individuals' current assessments to ensure all required information is included as per 2380.181(e)(1)-(15). (AS 3/13/18)] 02/21/2018 Implemented
SIN-00108930 Renewal 02/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1, date of admission 5/13/16 had a physical examination completed on 7/20/16.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.On 2/24/2017, TTSR CEO met with TTSR Residential Coordinator, as well as TTSR Assistant Director who is involved in the referral, review, and transition process for all newly admitted consumers to TTSR¿s program. A discussion/ training was had on the need for a physical to be on file within 12 months of the admission date for newly admitted individuals into TTSR¿s care. The Residential Coordinator states that when a new admission comes to TTSR, that she will ensure that the individual has a completed physical with all necessary information printed on the document along with authorized signatures. TTSR CEO will oversee this process by checking all newly admitted consumers¿ physicals before admission to TTSR is authorized. 03/06/2017 Implemented
SIN-00090961 Renewal 02/24/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)An unannounced fire drill was not held in September 2015.An unannounced fire drill shall be held at least once a month.During ATF licensing inspection on 2/24/2016, it was found that TTSR did not complete a monthly unannounced fire drill was not performed for the month of September 2015. The reason for this area of non-compliance was that the former ATF Supervisor was relieved of her duties at the start of September 2015. TTSR conducted a thorough interview process to find a suitable replacement for this job duty. On 11/4/2015, TTSR hired Nicole Englert to act as the permanent ATF Supervisor. During Nicole¿s training, Nicole received training on how to properly do unannounced monthly fire drills and to document required information on TTSR¿s Fire Drill document. Information needed on this document will include: -Date -Time -Amount of time it took to evacuate -Exit route used -Problems encountered -Whether the fire alarm or smoke detector was operative. In the event that the ATF Supervisor position becomes vacant, TTSR Compliance Officer, Joshua Altman, will be tasked with making sure that there are no lapses in monthly unannounced fire drills and will perform the fire drill for any month that there has not been a fire drill conducted until a new ATF Supervisor can be hired and trained properly on this requirement. [At least quarterly or the next 6 months after receipt of the plan of correction, Compliance Officer or designated management staff person will review fire drill documentation to ensure fire drills are completed and documented as required. Documentation of reviews shall be kept. (AS 5/18/16)] 03/16/2016 Implemented
2380.89(c)The written fire drill record for the fire drill held on 11-12-2015 did not include the amount of time it took for evacuations. 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 was operative.A training was held on 3/16/2016 to discuss areas of non-compliance found during annual ATF licensing held on 2/24/2016 (The written fire drill record for the fire drill held on 11-12-2015 did not include the amount of time it took for evacuations). [Documentation of monthly reviews of fire drill records shall be kept. (AS 5/18/16)] Denise Babcock (secretary), acknowledge that she will, on a monthly basis, be responsible for the review of all fire drills submitted to the TTSR Administrative Office to ensure that staff who conducted the fire drill are completely filling all necessary sections of the fire drill report to include: - Date of fire drill - Time of fire drill (unannounced) - Amount of time it took to evacuate - Exit route used - Problems encountered during fire drill - Whether the fire alarm or smoke detector was operative. Nicole Englert (ATF Supervisor), acknowledge that she will adhere to regulation 89 (d) and document what time that fire drill took place every time that we perform such a test so as to remain in compliance. 03/16/2016 Implemented
2380.186(b)Individual #1 did not sign and date the 3 month ISP reviews ending on 8-2-2015 and 11-2-2015.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.On Wednesday, 3/16/2016, TTSR CEO met with all TTSR Program Specialists who are in charge of attending all TTSR consumers¿ 3 month reviews of the ISP. The topic of this meeting/ training was to discuss the need for Program Specialists to ensure the following: 1) All team members attending the 3 month ISP review meetings will sign and date the review documentation. Signatures and dates for all individuals being discussed are to be present on the sign in sheet unless the individual refuses to sign. In the event that the individual refuses to sign the sign in sheet, TTSR will indicate in writing the individual¿s refusal on this sign in sheet. By signing the attached signature page, all Program Specialists acknowledge that they received the training on the above mentioned topics on 3/16/2016 and attest that they understand that these steps must be done for all ISP reviews. TTSR Program Specialists will be tasked with oversight on this matter to ensure that all ISP documentation is filled out properly and contain required information at the conclusion of each meeting. [At least quarterly for 1 year, CEO or designated management staff person will review a 10% sample of individual ISP reviews to ensure individuals are signing as required. Documentation of reviews shall be kept. (AS 5/18/16) 03/16/2016 Implemented
SIN-00073244 Renewal 02/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility did not have an annual onsite fire safety inspection by a fire safety expert in 2013 or 2014.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.On 3/16/2015, Fire Chief for Rimersburg Fire Department came to TTSR ATF Building to conduct a thorough fire safety inspection of the the ATF Building located at 2241 Whitmer Road in Sligo, PA. Attached is an inspection form indicating that the structure meets all state regulations pertaining to fire safety. This inspection will be conducted on a yearly basis (within a year of this inspection). TTSR Assistant Director will be in charge of ensuring that this inspection does take place on a yearly basis. TTSR Assistant Director has read the regulations regarding this area of non-compliance and fully understands to need for this fire safety inspection. 03/16/2015 Implemented
2380.173(1)(ii)Individual #1's record did not include identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.On 2/23/2015, TTSR CEO met with TTSR Residential Coordinator as well as Program Specialists who oversee the caseloads for Individual #1 and all of TTSR¿s consumers, and a discussion/ training was had on the need for any identifying marks/ characteristics for newly admitted individuals into TTSR¿s care to be noted on the individual¿s Identification Sheet. The Program Specialists stated that when a new admission comes to TTSR, that he/ she will ensure that this question is asked of the individual (if not already identified on the TTSR Admission packet prior to admission) and will mark any physical identifying marks down on their admission packet. If any identifying marks or characteristics are found during the initial intake process interview, the Program Specialist will convey this information (as well as other pertinent information required on the individual¿s Identification Sheet) to the TTSR Residential Coordinator who is in charge of completing the Identification Sheet to be maintained on the TTSR server as well as in the Individual¿s documentation books. TTSR Assistant Director will oversee this process by checking all newly admitted consumer¿s identification sheets a day or two after initial day of admission. Attached is a copy of individual #1¿s Personal Identification Sheet which shows that the individual was asked by TTSR Program Specialist, if he had any identifying marks and the individual stated that he did not (2/23/2014). Program Specialist also relayed to Residential Coordinator that no identifying marks were found at initial intake interview. For this reason, TTSR has marked on Individual #1¿s Identification Sheet ¿None¿ for Identifying Characteristics/ Marks. 02/23/2015 Implemented
2380.173(1)(iv)Individual #1's record did not include the religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.On 2/23/2015, TTSR CEO met with TTSR Residential Coordinator as well as Program Specialists who oversee the caseloads for Individual #1 and all of TTSR¿s consumers, and a discussion/ training was had on the need to inquire to all TTSR consumers their choice of religious affiliation upon admission to TTSR. The Program Specialists stated that when a new admission comes to TTSR, that he/ she will ensure that this question is asked of the individual (if not already identified on the TTSR Admission packet prior to admission). Once a religious affiliation has been determined, the Program Specialist will convey this information (as well as other pertinent information required on the individual¿s Identification Sheet) to the TTSR Residential Coordinator who is in charge of completing the Identification Sheet to be maintained on the TTSR server as well as in the Individual¿s documentation books. TSR Assistant Director will oversee this process by checking all newly admitted consumer¿s identification sheets a day or two after initial day of admission. Attached is a copy of individual #1¿s Personal Identification Sheet which shows that the individual was asked by TTSR program Specialist, what his choice of religious affiliation was or which affiliation he wished to be. The individual stated that he did not have a cholice or preference at this time and did not wish to choose. TTSR will consider Individual #1 ¿non-denominational¿ for now unless Individual #1 chooses a religious affiliation at a later date. 02/23/2015 Implemented
2380.173(6)(ii)Individual #2's record did not include a completed copy of the signature sheet for the ISP annual update meeting held on September 8, 2014.Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting.On 2/23/2015, TTSR CEO met with all TTSR Program Specialists who are in charge of attending all TTSR consumers¿ 3 month reviews of the ISP. 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 Specialist shall maintain the signature page for all ISP meetings in the individual¿s records. Attached is a sign in sheet for all attendees of this meeting. Also attached is a copy of the signature sheet that was forwarded to TTSR by Individual #2's Supports Coordinator (dated 9/10/2014). 02/23/2015 Implemented
SIN-00044057 Renewal 11/05/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(1)The Assessment for Individual #1 had a Strengths and Needs section that was left blank.(e)  The assessment must include the following information: (1)  Functional strengths, needs and preferences of the individual.The Strengths and Needs section has been completed as required. This area of the Assessment was also submitted regarding 2 other individuals in the program. TTSR staff were trained on the Assessment by the program coordinator on February 25, 2013. The persons responsible for the implementation of this document are the program coordinator and the respective program specialist. This will be monitored on a monthly basis. 11/05/2012 Implemented
2380.181(e)(9)For all Assessments, there needs to be a section that addresses the individual's disability and functional medical limits. (e)  The assessment must include the following information: (9)  Documentation of the individual's disability, including functional and medical limitations.Provider has added to Assessment section that address individuals disablity and functional medical limits. This area of the Asssessment was also submitted for two other individuals. The TTSR staff were trained on the Assessment by the program coordinator on February 25, 2013. The person responsible for implementing this procedure in the future is either the program coordinator or the respective program specialist. The monitoring for this procedure will occur on a monthly basis. 11/05/2012 Implemented
2380.181(e)(10)The Assessment for Individual #2 did not contain a Lifetime Medical History. Partially Implemented with Adequate Progress. KD March 12, 2013. (e)  The assessment must include the following information: (10)  A lifetime medical history.A lifetime medical history area was added to the Assessment, and there were two other Assessments from other individuals submitted which also had lifetime medical histories. Also, the TTSR staff was trained on the Assessment by the program coordinator on February 25, 2013. The persons responsible for this being implemented in the future are either the program coordinator or the respective program specialist, and this will be monitored on a monthly basis. 01/28/2013 Implemented
SIN-00222932 Renewal 04/18/2023 Compliant - Finalized
SIN-00205034 Renewal 04/21/2022 Compliant - Finalized
SIN-00057457 Renewal 03/20/2014 Compliant - Finalized