Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238692 Renewal 01/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(c)Individual #1 is prescribed Asenapine Sub 10 MG with directions to dissolve one tablet by mouth twice a day for mood disorder. This was not administered from 1/11/2024 at 8 AM through 1/15/2024 at 8 AM due to the pharmacy not being able to refill the medication timely.A prescription medication shall be administered as prescribed.During review of MAR during licensing inspection, it was learned that Individual#1 did not receive a medication as prescribed. Individual#1 is prescribed Asenapine to be taken one time daily. Medication was apparently not given from January 11-15th. TTSR Residential Coordinator called the pharmacy and the pharmacy stated that Site Supervisor attempted to get a refill of the medication on the 10th of January. The pharmacy stated that they did not fill the prescription because the insurance would not pay for a refill at that time. TTSR asked the pharmacy why they did not contact TTSR to inform them of the insurance issue and pharmacy did not have an answer to this question. To ensure compliance in the future, TTSR Site Supervisor will continue to monitor medication counts as they have by doing medication counts three times daily (at the end of every 8 hour shift). When this medication is at a point where there is exactly 7 days until the medication needs refilled, Site Supervisor will contact TTSR Administration and Residential Coordinator will contact the pharmacy to ensure that there will be no issues or recurrence of this type of incident in the future. A review (with Site Supervisor as well as Residential Coordinator ) of regulation 165(c) took place on 2/8/2024 as well as a training on the above mentioned protocol for ensuring that the medication will be filled and that insurance will cover 7 days prior to needing medication refilled. 02/08/2024 Implemented
SIN-00219566 Renewal 02/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The 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
SIN-00071335 Renewal 11/05/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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
SIN-00183924 Renewal 02/25/2021 Compliant - Finalized
SIN-00126904 Renewal 12/28/2017 Compliant - Finalized