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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The annual furnace cleaning and inspection that was documented on 9/5/22 was not completed by a professional furnace cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| TTSR is currently in the process of seeking HVAC Certification for furnace inspection and cleaning for the TTSR Maintenance Department (who has completed the furnace inspection in the past for TTSR).
If for some reason, the TTSR Maintenance Department is unable to receive certification for furnace inspection and cleaning, TTSR will contact a local professional heating company who will clean and inspect all furnaces in all 6400 residential homes agency-wide at least annually and within 365 days of last furnace inspection/ cleaning |
02/28/2023
| Implemented |
| 6400.15(b) | The agency used a Department's licensing inspection instrument modified in June 2018. The current inspection summary instrument for the community homes for individuals with intellectual disability or autism was promulgated in February 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Per recommendations from licensing inspectors, TTSR was asked to download the Regulatory Compliance Guide for Pa. Code Chapter 6400 (February 14, 2023 Edition). On Page 22 of the RCG, TTSR found the link under Code 6400.15(b) which provides the updated Inspection tool for 6400 homes and includes all elements of the Department¿s instrument. Copies of this document have been downloaded and printed for future use and until a more updated version of the Inspection tool becomes available. Attached is a copy of the ¿55 Pa. Code Chapter 6400- Community Homes for Individuals with an Intellectual Disability or Autism¿ that will be used for future self assessments |
02/23/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There are ceiling tiles that are falling down on the right side as you enter the room. They are small square tiles and three of them were peeling and loose. | (a) Floors, walls, ceilings and other surfaces shall be in good repair.
| On 1/13/2014, TTSR Maintenance worker, Chris Arnold arrived at the TTSR operated site located at 4483 ROUTE 322, Clarion, KNOX, PA ¿ 16232. The purpose of this visit to the site was to replace ceiling tiles that were found to be loose and falling from the ceiling in the right corner of the room as you enter. Once at the site, Chris Arnold reports that he completed the following tasks:
*Cut out old loose and falling tiles
*Applied new tiles to the area of the ceiling
*Stapled and glued new tiles up to replace old and worn tiles
Attached in binder is a picture of the right corner of the ceiling (as you walk in) showing that the old and worn tiles have been replaced in the second floor storage room as of 1/13/2014.
All surfaces to include, but not be limited to ceilings, walls, floors, and surfaces will be inspected on a bi-monthly basis by TTSR Administrative staff to ensure that all sites meet the requirements set forth in 6400 regulations. Any needed repairs will be done on an as needed basis by TTSR Maintenance department so that all TTSR homes |
01/13/2014
| Implemented |
| 6400.81(k)(6) | There was no mirror located in Individual #1's bedroom. | 6400.81. Individual bedrooms.
(6) A mirror.
| On 2/7/2014, TTSR House Supervisor, George Hartzell placed a mirror on the wall of Individual #1's bedroom wall as per 6400 regulations (6400.81(k)(6)). (see attached photo). Mr. Hartzell also met with TTSR Assistant Director Matthew Gladin to discuss regulation 6400.81 (k)(6) and that all individuals are to have a mirror in their bedroom. This meeting took place on 2/7/2014 at the TTSR Administrative Office.
All bedrooms agency-wide will be inspected on a bi-monthly basis by TTSR Administrative staff to ensure that all sites meet the requirements set forth in 6400 regulations. If it has been determined that the mirror in this individual¿s bedroom becomes a safety hazard to the individual or his staff, then TTSR will apply for a waiver to restrict this mirror from Individual¿s bedroom but until this time, the mirror will remain in Individual #1¿s bedroom until a waiver has been approved.
By signing below, George Hartzell acknowledges that he conducted the above mentioned task to ensure that Individual #1 has a mirror on his bedroom wall at the site located at 4483 Route 322 in Knox, PA. and that this mirror meets the licensing regulations. Also, Mr. Hartzell also acknowledges that he understands regulation 6400.81 (k)(6)as well as all 6400 regulations and will be responsible for ensuring that the home that he supervises continues to meet all areas of compliance.
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02/14/2014
| Implemented |
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